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Tordoff DM, Restar A, Minalga B, Fernandez A, Dimitrov D, Duerr A. Including transgender populations in mathematical models for HIV treatment and prevention: current barriers and policy implications. J Int AIDS Soc 2024; 27:e26304. [PMID: 38867431 PMCID: PMC11168965 DOI: 10.1002/jia2.26304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 05/23/2024] [Indexed: 06/14/2024] Open
Abstract
INTRODUCTION Mathematical models of HIV have been uniquely important in directing and evaluating HIV policy. Transgender and nonbinary people are disproportionately impacted by HIV; however, few mathematical models of HIV transmission have been published that are inclusive of transgender and nonbinary populations. This commentary discusses current structural challenges to developing robust and accurate trans-inclusive models and identifies opportunities for future research and policy, with a focus on examples from the United States. DISCUSSION As of April 2024, only seven published mathematical models of HIV transmission include transgender people. Existing models have several notable limitations and biases that limit their utility for informing public health intervention. Notably, no models include transgender men or nonbinary individuals, despite these populations being disproportionately impacted by HIV relative to cisgender populations. In addition, existing mathematical models of HIV transmission do not accurately represent the sexual network of transgender people. Data availability and quality remain a significant barrier to the development of accurate trans-inclusive mathematical models of HIV. Using a community-engaged approach, we developed a modelling framework that addresses the limitations of existing model and to highlight how data availability and quality limit the utility of mathematical models for transgender populations. CONCLUSIONS Modelling is an important tool for HIV prevention planning and a key step towards informing public health interventions, programming and policies for transgender populations. Our modelling framework underscores the importance of accurate trans-inclusive data collection methodologies, since the relevance of these analyses for informing public health decision-making is strongly dependent on the validity of the model parameterization and calibration targets. Adopting gender-inclusive and gender-specific approaches starting from the development and data collection stages of research can provide insights into how interventions, programming and policies can distinguish unique health needs across all gender groups. Moreover, in light of the data structure limitations, designing longitudinal surveillance data systems and probability samples will be critical to fill key research gaps, highlight progress and provide additional rigour to the current evidence. Investments and initiatives like Ending the HIV Epidemic in the United States can be further expanded and are highly needed to prioritize and value transgender populations across funding structures, goals and outcome measures.
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Affiliation(s)
- Diana M. Tordoff
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- School of MedicineStanford UniversityPalo AltoCaliforniaUSA
| | - Arjee Restar
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | | | | | - Dobromir Dimitrov
- Fred Hutchinson Cancer CenterSeattleWashingtonUSA
- Department of Applied MathematicsUniversity of WashingtonSeattleWashingtonUSA
| | - Ann Duerr
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Fred Hutchinson Cancer CenterSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
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Pignedoli C, Rivest P. The gender of PrEP: Transgender men negotiating legitimacy in France. Soc Sci Med 2024; 348:116842. [PMID: 38593613 DOI: 10.1016/j.socscimed.2024.116842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 01/05/2024] [Accepted: 03/26/2024] [Indexed: 04/11/2024]
Abstract
Transmasculine people (TM) constitute an invisibilized group within the transgender population. Little is known about their relationship to sexuality in transgender medicine. Their presence and needs are still unacknowledged within HIV prevention research and services. Pre-exposure prophylaxis (or PrEP) is an oral medication that prevents HIV in HIV-negative individuals at risk of infection with the virus. This paper proposes to bring TM back into the focus of PrEP research by questioning how they navigate and situate themselves in relation to existing PrEP categorization and services, and how they think about and (re)shape the meanings of PrEP. It is based on the "interpretative descriptive" method and a transfeminist theoretical framework applied to the analysis of ten semi-structured interviews with TM conducted in France between 2019 and 2023. Findings show that PrEP is gendered. We identify specific barriers to getting PrEP as well as to access healthcare and we show that a cisnormative and homonormative approach to prevention generates them. PrEP use and PrEP disclosure are embedded in structural and symbolic power relations between cisgender and transgender MSM that are reflected in the intimate sphere. TM use PrEP to prevent sexual assault and to alleviate the difficulty of condom negotiation. PrEP comes into play following major changes in TM's sexualities and is integrated post-exposure.
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Affiliation(s)
- Clark Pignedoli
- Université d'Aix-Marseille, SESSTIM - SanteRCom, Faculté de Médecine, 27 Bd Jean Moulin, 13385, Marseille, Cedex 5, France.
| | - Paul Rivest
- Université d'Aix-Marseille, Ideas, 5 rue du Château de l'Horloge, 13090, Aix-en-Provence, France.
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3
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Maragh-Bass AC, Kiplagat S, Lavari S, Sastre F, Devieux JG, Jimenez D, Clarke RD, Noel I, Schrimshaw EW, Sevelius J, Cyrus E. Barriers to Accessing and Engaging in HIV Preventive Care and Pre-Exposure Prophylaxis Experienced by Transgender Women in Florida. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:376. [PMID: 38541377 PMCID: PMC10970227 DOI: 10.3390/ijerph21030376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/15/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND PrEP, a biomedical HIV prevention option, continues to be underutilized among transgender women who could benefit from sustained use, especially women of color and those who identify as Latina and/or reside in the southeastern US. OBJECTIVE We explored the barriers and facilitators experienced by transgender women who live in Florida regarding accessing, using, and/or staying on PrEP. METHODS In-depth interviews and focus groups were conducted in either Spanish or English with adult transgender women living in Florida (N = 22). The interviews were audio-recorded, transcribed, and coded in ATLAS.ti using thematic analyses. RESULTS The mean age of the participants was 42.2 years. Among the participants, 73% were Hispanic/Latina, 59% were foreign-born, and approximately one-third were living with HIV (but had past experience with PrEP). Transgender women cited the following barriers to accessing or considering PrEP: (1) costs and benefits of PrEP use; (2) under-representation in clinical trials resulting in unknown or misinformation regarding PrEP side effects; (3) chronic poverty; and (4) trauma and discrimination. Other stressors, such as behavioral healthcare needs, were identified. CONCLUSIONS Our analysis revealed interlocking systems of oppression like transphobia, discrimination, and misgendering, which were common barriers experienced by our participants. These synergistically epidemic (i.e., syndemic) barriers contributed to their feelings of being systematically excluded in social spaces, research, public health planning and policies, laws, and social programs related to PrEP. These structural barriers are impediments to HIV preventive care but also act as a source of stress that contributes to mental health problems, financial vulnerability, substance abuse, and other deleterious health outcomes.
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Affiliation(s)
- Allysha C. Maragh-Bass
- Global Health and Population Division, FHI 360, Durham, NC 27701, USA
- Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, FL 32827, USA
| | - Sandra Kiplagat
- Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL 33199, USA
| | - Sarah Lavari
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
| | - Francisco Sastre
- Department of Psychology, Carlos Albizu University, Miami, FL 33172, USA
| | - Jessy G. Devieux
- Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL 33199, USA
| | - Daniel Jimenez
- Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL 33199, USA
| | - Rachel D. Clarke
- Department of Medical Education, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Ines Noel
- Department of Psychology, College of Arts and Science, New York University, New York City, NY 10003, USA
| | - Eric W. Schrimshaw
- Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, FL 32827, USA
| | - Jae Sevelius
- Department of Prevention Science, University of California, San Francisco, CA 94158, USA
- Department of Psychiatry, Division of Gender, Health, and Sexuality, Irving Medical Center, Columbia University, New York, NY 10032, USA
| | - Elena Cyrus
- Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, FL 32827, USA
- Department of Prevention Science, University of California, San Francisco, CA 94158, USA
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Ard KL, MacDonald-Ly A, Demidont AC. Sexual Health Care for Transgender and Gender Diverse People. Med Clin North Am 2024; 108:393-402. [PMID: 38331487 DOI: 10.1016/j.mcna.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
The proportion of people who identify as transgender and gender diverse (TGD) is increasing. Health care for TGD people, including sexual health care, must affirm and respect patients' gender identities and expressions. Here, the authors outline strategies to make health care settings more welcoming to and inclusive of TGD people and describe concrete steps to improve sexual health care for TGD populations.
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Affiliation(s)
- Kevin L Ard
- Harvard Medical School; Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Andrew MacDonald-Ly
- Gilead Sciences, Inc, HIV Global Medical Affairs, 333 Lakeside Drive, Foster City, CA 94404, USA
| | - A C Demidont
- Gilead Sciences, Inc, HIV Treatment Medical Affairs, 333 Lakeside Drive, Foster City, CA 94404, USA
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Andrzejewski J, Pines HA, Morris S, Burke L, Bolan R, Sevelius J, Moore DJ, Blumenthal J. Determinants of HIV Pre-Exposure Prophylaxis (PrEP) Retention among Transgender Women: A Sequential, Explanatory Mixed Methods Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:133. [PMID: 38397624 PMCID: PMC10888369 DOI: 10.3390/ijerph21020133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 02/25/2024]
Abstract
Transgender women (TW) face inequities in HIV and unique barriers to PrEP, an effective biomedical intervention to prevent HIV acquisition. To improve PrEP retention among TW, we examined factors related to retention using a two-phase, sequential explanatory mixed methods approach. In Phase I, we used data from a trial of 170 TW who were provided oral PrEP to examine predictors of 24-week retention. In Phase II, we conducted 15 in-depth interviews with PrEP-experienced TW and used thematic analysis to explain Phase I findings. In Phase I, more participants who were not retained at 24 weeks reported sex work engagement (18% versus 7%) and substantial/severe drug use (18% versus 8%). In Phase II, participants reported drug use as a barrier to PrEP, often in the context of sex work, and we identified two subcategories of sex work. TW engaged in "non-survival sex work" had little difficulty staying on PrEP, while those engaged in "survival sex work" struggled to stay on PrEP. In Phase I, fewer participants not retained at 24 weeks reported gender-affirming hormone therapy (GAHT) use (56% versus 71%). In Phase II, participants prioritized medical gender affirmation services over PrEP but also described the bidirectional benefits of accessing GAHT and PrEP. TW who engaged in "survival sex work" experience barriers to PrEP retention (e.g., unstable housing, drug use) and may require additional support to stay in PrEP care.
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Affiliation(s)
- Jack Andrzejewski
- San Diego Joint Doctoral Program in Public Health, San Diego State University—University of California San Diego, San Diego, CA 92093, USA
| | - Heather A. Pines
- School of Public Health, San Diego State University, San Diego, CA 92182, USA;
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA 92093, USA
- Department of Medicine, University of California San Diego, La Jolla, CA 92161, USA; (S.M.); (L.B.); (J.B.)
| | - Sheldon Morris
- Department of Medicine, University of California San Diego, La Jolla, CA 92161, USA; (S.M.); (L.B.); (J.B.)
| | - Leah Burke
- Department of Medicine, University of California San Diego, La Jolla, CA 92161, USA; (S.M.); (L.B.); (J.B.)
| | | | - Jae Sevelius
- Department of Psychiatry, Columbia University, New York, NY 10032, USA;
| | - David J. Moore
- Department of Psychiatry, University of California San Diego, La Jolla, CA 92093, USA;
| | - Jill Blumenthal
- Department of Medicine, University of California San Diego, La Jolla, CA 92161, USA; (S.M.); (L.B.); (J.B.)
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Harris LM, Kerr JC, Skidmore BD, Ghare S, Reyes-Vega A, Remenik-Zarauz V, Samanapally H, Anwar RU, Rijal R, Bryant K, Hall MT, Barve S. A conceptual analysis of SBIRT implementation alongside the continuum of PrEP awareness: domains of fit and feasibility. Front Public Health 2024; 11:1310388. [PMID: 38259734 PMCID: PMC10801388 DOI: 10.3389/fpubh.2023.1310388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/12/2023] [Indexed: 01/24/2024] Open
Abstract
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a supplementary intervention that can be incorporated into the Pre-Exposure Prophylaxis (PrEP) Care Continuum, complementing initiatives and endeavors focused on Human Immunodeficiency Virus (HIV) prevention in clinical care and community-based work. Referencing the Transtheoretical Model of Change and the PrEP Awareness Continuum, this conceptual analysis highlights how SBIRT amplifies ongoing HIV prevention initiatives and presents a distinct chance to address identified gaps. SBIRT's mechanisms show promise of fit and feasibility through (a) implementing universal Screening (S), (b) administering a Brief Intervention (BI) grounded in motivational interviewing aimed at assisting individuals in recognizing the significance of PrEP in their lives, (c) providing an affirming and supportive Referral to Treatment (RT) to access clinical PrEP care, and (d) employing client-centered and destigmatized approaches. SBIRT is uniquely positioned to help address the complex challenges facing PrEP awareness and initiation efforts. Adapting the SBIRT model to integrate and amplify HIV prevention efforts merits further examination.
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Affiliation(s)
- Lesley M. Harris
- Kent School of Social Work & Family Science, University of Louisville, Louisville, KY, United States
| | - Jelani C. Kerr
- Department of Health Promotion and Behavioral Sciences, University of Louisville, Louisville, KY, United States
| | - Blake D. Skidmore
- Kent School of Social Work & Family Science, University of Louisville, Louisville, KY, United States
| | - Smita Ghare
- School of Medicine, University of Louisville, Louisville, KY, United States
| | - Andrea Reyes-Vega
- School of Medicine, University of Louisville, Louisville, KY, United States
| | | | | | - Rana Usman Anwar
- School of Medicine, University of Louisville, Louisville, KY, United States
| | - Rishikesh Rijal
- School of Medicine, University of Louisville, Louisville, KY, United States
| | - Kendall Bryant
- HIV/AIDS Research, National Institute on Alcohol Abuse and Alcoholism (NIAAA), Bethesda, MD, United States
| | - Martin T. Hall
- Kent School of Social Work & Family Science, University of Louisville, Louisville, KY, United States
| | - Shirish Barve
- School of Medicine, University of Louisville, Louisville, KY, United States
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Janamnuaysook R, Guo Y, Yu YJ, Phanuphak N, Kawichai S, MacDonell K, Jupimai T, Rongkavilit C, Wang B. Lived experiences with pre-exposure prophylaxis uptake and adherence among transgender women in Thailand: a qualitative study. Sex Health 2024; 21:SH23102. [PMID: 38219741 DOI: 10.1071/sh23102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Transgender women (TGW) are disproportionately affected by HIV, and HIV prevalence among TGW in Thailand has been increasing. Although oral daily pre-exposure prophylaxis (PrEP) is effective for HIV prevention, PrEP uptake and persistence among TGW have been low. This study aimed to provide a deeper understanding of TGW's experiences with PrEP uptake and adherence, and to identify major barriers to PrEP use to inform intervention adaptation. METHODS We interviewed 20 young TGW (six non-PrEP users, eight adherent, six non-adherent) and 10 health care providers from two HIV clinics in Bangkok, Thailand, in 2022. We focused on understanding challenges to PrEP use in this population using an interview guide based on a theoretical model of behaviour change and thematic content analysis. RESULTS Thematic analysis identified major barriers to and facilitators of PrEP uptake and adherence. Barriers to PrEP initiation included low self-perceived HIV risk, concern about potential side-effects, patient burdens such as frequent HIV testing for prescription refills and social stigma against PrEP. Barriers to adherence included side-effects, inconvenient access to health services (especially during COVID-19 lockdowns), forgetfulness resulting from busy schedules and low self-perceived HIV risk. TGW also reported health care providers' stigma against PrEP users deterred them from seeking further PrEP services. TGW identified major facilitators of PrEP initiation, including awareness about the benefits of PrEP, concern about risks of HIV and supportive social networks of PrEP users. As to PrEP regimens, most TGW participants reported a clear preference for long-lasting, injectable PrEP over daily oral PrEP. TGW and health care providers largely agreed on barriers and facilitators of PrEP use, but they differed in perceptions of HIV risk. CONCLUSIONS The results highlighted challenges and opportunities to improve the delivery of PrEP, as well as other sexually transmissable infection and mental health services, especially among TGW. Thus, there is an urgent need for developing effective intervention programs that could raise PrEP awareness and knowledge, reduce PrEP stigma, and improve PrEP delivery systems among TGW in Thailand.
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Affiliation(s)
- Rena Janamnuaysook
- Institute of HIV Research and Innovation, Bangkok, Thailand; and Center of Excellence in Transgender Health (CETH), Chulalongkorn University, Bangkok, Thailand
| | - Yan Guo
- Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Yeon Jung Yu
- Department of Anthropology, Western Washington University, Bellingham, WA, USA
| | - Nittaya Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand; and Center of Excellence in Transgender Health (CETH), Chulalongkorn University, Bangkok, Thailand
| | - Surinda Kawichai
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Karen MacDonell
- Center for Translational Behavioral Research, Florida State University, Tallahassee, FL, USA
| | - Thidarat Jupimai
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Chokechai Rongkavilit
- Department of Pediatrics, University of California San Francisco-Fresno Branch Campus, Fresno, CA, USA
| | - Bo Wang
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Marzinke MA, Hanscom B, Wang Z, Safren SA, Psaros C, Donnell D, Richardson PA, Sullivan P, Eshleman SH, Jennings A, Feliciano KG, Jalil E, Coutinho C, Cardozo N, Maia B, Khan T, Singh Y, Middelkoop K, Franks J, Valencia J, Sanchez N, Lucas J, Rooney JF, Rinehart AR, Ford S, Adeyeye A, Cohen MS, McCauley M, Landovitz RJ, Grinsztejn B. Efficacy, safety, tolerability, and pharmacokinetics of long-acting injectable cabotegravir for HIV pre-exposure prophylaxis in transgender women: a secondary analysis of the HPTN 083 trial. Lancet HIV 2023; 10:e703-e712. [PMID: 37783219 PMCID: PMC10842527 DOI: 10.1016/s2352-3018(23)00200-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND The HIV Prevention Trials Network (HPTN) 083 trial showed that long-acting injectable cabotegravir was more effective than tenofovir disoproxil fumarate plus emtricitabine in preventing HIV in cisgender men and transgender women who have sex with men. We aimed to characterise the cohort of transgender women included in HPTN 083. METHODS HPTN 083 is an ongoing, phase 2b/3, randomised, multicentre, double-blind, double-dummy clinical trial done at 43 sites in seven countries (Argentina, Brazil, Peru, the USA, South Africa, Thailand, and Viet Nam). HIV-negative participants were randomly assigned (1:1) to receive injectable cabotegravir or tenofovir disoproxil fumarate plus emtricitabine. The study design and primary outcomes of the blinded phase of HPTN 083 have already been reported. An enrolment minimum of 10% transgender women was set for the trial. Here we characterise the cohort of transgender women enrolled from Dec 6, 2016, to May 14, 2020, when the study was unblinded. We report sociodemographic characteristics, use of gender affirming hormone therapy, and behavioural assessments of the transgender women participants. Laboratory testing and safety evaluations are also reported. The trial is registered at ClinicalTrials.gov, NCT02720094. FINDINGS HPTN 083 enrolled 570 transgender women (304 tenofovir disoproxil fumarate plus emtricitabine; 266 injectable cabotegravir). Transgender women were primarily from Asia (225 [39%]) and Latin America (205 [36%]); 330 (58%) reported using gender affirming hormone therapy. Intimate partner violence was common (270 [47%] reported emotional abuse and 172 [30%] reported physical abuse) and 323 (57%) reported a history of childhood sexual abuse. 159 (28%) transgender women disagreed that they were at risk for HIV, and 142 (25%) screened positive for depressive symptoms. During study follow-up, incidence of syphilis was 16·25% (95% CI 13·28-19·69), rectal gonorrhoea was 11·66% (9·14-14·66), and chlamydia was 20·61% (17·20-24·49). Frequency of adverse events was similar between the treatment groups. Nine seroconversions occurred among transgender women during the blinded phase of the study (seven in the tenofovir disoproxil fumarate plus emtricitabine group and two in the injectable cabotegravir group); overall incidence was 1·19 per 100 person-years (95% CI 0·54-2·25): 1·80 per 100 person-years (0·73-3·72) in the tenofovir disoproxil fumarate plus emtricitabine group and 0·54 per 100 person-years (0·07-1·95) in the injectable cabotegravir group (hazard ratio 0·34 [95% CI 0·08-1·56]). Cabotegravir concentrations did not differ by gender affirming hormone therapy use. INTERPRETATION HIV prevention strategies for transgender women cannot be addressed separately from social and structural vulnerabilities. Transgender women were well represented in HPTN 083 and should continue to be prioritised in HIV prevention studies. Our results suggest that injectable cabotegravir is a safe and effective pre-exposure prophylaxis option for transgender women. FUNDING National Institute of Allergy and Infectious Diseases and ViiV Healthcare.
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Affiliation(s)
| | | | - Zhe Wang
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | | | | | | | | | | | | | | | - Emilia Jalil
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Manguinhos, Rio de Janeiro, Brazil
| | - Carolina Coutinho
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Manguinhos, Rio de Janeiro, Brazil
| | | | | | | | - Yashna Singh
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Keren Middelkoop
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | | | | | | | | | - Myron S Cohen
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Raphael J Landovitz
- Center for Clinical AIDS Research and Education, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Manguinhos, Rio de Janeiro, Brazil.
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Tordoff DM, Fernandez A, Perry NL, Heberling WB, Minalga B, Khosropour CM, Glick SN, Barbee LA, Duerr A. A Quantitative Intersectionality Analysis of HIV/STI Prevention and Healthcare Access Among Transgender and Nonbinary People. Epidemiology 2023; 34:827-837. [PMID: 37756272 PMCID: PMC10539029 DOI: 10.1097/ede.0000000000001669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND Transgender and nonbinary people experience substantial barriers to accessing healthcare, including prevention of HIV and other sexually transmitted infections (HIV/STI), due to structural inequities. We examined differences in insurance, HIV/STI prevalence, testing, and preexposure prophylaxis use among transgender and nonbinary people living in Washington State by race and ethnicity and gender. METHODS We pooled data from five 2019-2021 Washington State HIV/STI surveillance data sources to obtain a large and diverse sample of 1648 transgender and nonbinary participants. We calculated the risk difference (RD) for each outcome and used Poisson regression to estimate a surrogate measure of additive interaction-attributable proportion (AP)-that measures the proportion of the excess prevalence of the outcome observed at the intersection of gendered and racialized experience, beyond that expected from gender or race and ethnicity alone. RESULTS Participants reported overall high levels of poverty (29% incomes <$15,000 and 7% unstable housing). Certain groups, especially racial/ethnic minority transgender women, were disproportionately impacted by HIV/STIs (RDs from 20% to 43% and APs from 50% to 85%) and less likely to currently have insurance (RDs from 25% to 39% and APs from 74% to 93%) than that expected based on gendered or racialized experience alone. CONCLUSIONS Our findings highlight the heterogeneity in insurance access, HIV/STI positivity, and prevention utilization within transgender communities. We observed that a large proportion of increased HIV/STI prevalence among racial/ethnic minority transgender women was attributable to the intersection of gender and race and ethnicity. Our findings highlight the importance of trans-inclusive models of HIV/STI prevention that address multilevel barriers rooted in cissexism and structural racism.
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Affiliation(s)
- Diana M. Tordoff
- University of Washington, Department of Epidemiology, Seattle, WA
| | | | - Nicole Lynn Perry
- Lavender Rights Project, Washington Black Trans Task Force, Seattle, WA
| | | | | | | | - Sara N. Glick
- University of Washington, School of Medicine, Seattle, WA
- Public Health-Seattle & King County HIV/STD Program, Seattle, WA
| | - Lindley A. Barbee
- University of Washington, School of Medicine, Seattle, WA
- Public Health-Seattle & King County HIV/STD Program, Seattle, WA
| | - Ann Duerr
- Fred Hutchinson Cancer Center, Seattle, WA
- Department of Global Health, University of Washington, Seattle, WA
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Zarwell M, Witt B, Marin-Cespedes S, Gorman B, Kumtap MU, Hoff R, Rysbayeva A, Jha P, Boehm EL, Harihar S, Issel LM, Robinson P. Uptake and Discontinuation of Pre-Exposure Prophylaxis Among Uninsured Transgender and Cisgender Women: A Public-Private Partnership Model in North Carolina. AIDS Patient Care STDS 2023; 37:525-534. [PMID: 37956243 DOI: 10.1089/apc.2023.0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
HIV pre-exposure prophylaxis (PrEP) remains underutilized among cis and trans women. The PrEP Initiative Program (PIP) is a novel public-private partnership implemented at 12 local clinics in North Carolina. PIP provides HIV/sexually transmitted infection (STI) testing and clinical and laboratory monitoring for PrEP to uninsured/underinsured clients. We sought to understand service-related differences among both cis and trans women enrolled in PIP, including STIs diagnoses, clinic type, sources of referral, services needed, and reasons for PrEP discontinuation. The Kaplan-Meier curves display retention on PrEP over the duration of the program. Since 2018, 142 women (cis n = 113; trans n = 29) enrolled, and 136 started PrEP. The majority were ages 25-34 years (31.7%) or 18-24 years (29.6%), Black (57.8%) or Latinx (24.7%). Approximately 20.6% of recipients reported at least one STI while enrolled. Overall, trans women requested fewer services than cis women. After accounting for the amount of time each patient was taking PrEP, there were higher rates of trans women diagnosed with syphilis than cis women. Rates of persons with other STIs were not notably different between trans and cis women. Clinic access varied by gender: 69% of trans women were enrolled at only one site. Trans women were retained significantly longer: The Kaplan-Meier adjusted median time to discontinuation was 560 and 238 days for trans and cis women, respectively. PIP successfully reached historically marginalized and uninsured cis and trans women who may benefit from PrEP. Further investigations into factors contributing to recruitment and retention of women in HIV prevention programs are needed.
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Affiliation(s)
- Meagan Zarwell
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
- Academy for Population Health Innovation, UNC Charlotte, Charlotte, North Carolina, USA
| | - Brian Witt
- Academy for Population Health Innovation, UNC Charlotte, Charlotte, North Carolina, USA
- HIV/STI Division, Mecklenburg County Public Health Department, Charlotte, North Carolina, USA
| | - Sebastian Marin-Cespedes
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
- Academy for Population Health Innovation, UNC Charlotte, Charlotte, North Carolina, USA
| | - Brianna Gorman
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
| | - Makshwar U Kumtap
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
| | - Rhoen Hoff
- Department of Psychology, UNC Charlotte, College of Liberal Arts and Sciences, Charlotte, North Carolina, USA
| | - Ainella Rysbayeva
- Department of Biology, UNC Charlotte, College of Liberal Arts and Sciences, Charlotte, North Carolina, USA
| | - Prashant Jha
- Department of Biology, UNC Charlotte, College of Liberal Arts and Sciences, Charlotte, North Carolina, USA
| | - Elsa L Boehm
- BASIS DC High School, Washington, District of Columbia, USA
| | - Sweta Harihar
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
- Academy for Population Health Innovation, UNC Charlotte, Charlotte, North Carolina, USA
| | - L Michele Issel
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
| | - Patrick Robinson
- Department of Public Health Sciences, UNC Charlotte, College of Health and Human Services, Charlotte, North Carolina, USA
- Academy for Population Health Innovation, UNC Charlotte, Charlotte, North Carolina, USA
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11
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Camila-Bolívar M, Gomez-Peñaloza SA, Camargo-Plazas P, Peralta-Ardila MDP, Mueses-Marín HF, Alvarado-Llano B, Martínez-Cajas JL. Barriers and facilitators to HIV pre-exposure prophylaxis uptake among transgender women in Colombia: A qualitative analysis using the COM-B model. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001395. [PMID: 37756283 PMCID: PMC10529613 DOI: 10.1371/journal.pgph.0001395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 08/28/2023] [Indexed: 09/29/2023]
Abstract
Transgender women [TGW] in Colombia are disproportionately affected by HIV due to their low sociodemographic conditions, varied risk behaviours, difficulty accessing health services, and discrimination. Offering pre-exposure prophylaxis [PrEP] as part of a combination of prevention strategies is an appropriate option for this population to reduce their risk of HIV infection. However, little is known about how to implement a PrEP program for TGW in Colombia. Between June and October 2020, we conducted individual interviews with 16 TGW from four different cities in Colombia. The interviews assessed contextual influences, knowledge, skills, perceptions, and beliefs. We used qualitative thematic analysis to identify themes and the Capability, Opportunity, Motivation, and Behavior framework to further delineate barriers and possible interventions. After delineating the main themes across the three subdomains of the model, nine barriers were identified: one related to capability, knowledge, and perception of PrEP; six related to opportunity, which includes, family relations, sexual work environment, stable partner relations, interactions with healthcare workers, health service provision, and community interactions and opportunities; and two related to motivation, mental health, and concerns about medication side effects. Mapping barriers with interventions generated the following intervention functions: education, training, enablement, and environmental structure; and the following policy functions: communication/marketing, legislation, and changes in service provision. Examples of possible interventions are presented and discussed.
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Affiliation(s)
- Maria Camila-Bolívar
- Department of Public Health and Epidemiology, Pontificia Universidad Javeriana Cali, Cali, Colombia
- Corporación de Lucha Contra el Sida, Cali, Colombia
| | | | | | | | | | | | - Jorge L. Martínez-Cajas
- Division of Infectious Diseases, Department of Medicine, Queens University, Kingston, Ontario, Canada
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12
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Cattani VB, Jalil EM, Eksterman L, Torres T, Wagner Cardoso S, Castro CRV, Monteiro L, Wilson E, Bushman L, Anderson P, Veloso VG, Grinsztejn B, Estrela R. Estradiol and Spironolactone Plasma Pharmacokinetics Among Brazilian Transgender Women Using HIV Pre-Exposure Prophylaxis: Analysis of Potential Interactions. Clin Pharmacokinet 2023; 62:1031-1041. [PMID: 37261664 PMCID: PMC10338392 DOI: 10.1007/s40262-023-01248-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND OBJECTIVE An important barrier to HIV prevention among transgender women (TGW) is the concern that oral pre-exposure prophylaxis (PrEP) negatively affects the efficacy of feminizing hormone therapy (FHT). We aimed to assess the impact of PrEP on FHT pharmacokinetics (PK) among TGW from Brazil. METHODS We performed a drug-drug interaction sub-study among TGW enrolled in a daily oral PrEP demonstration study (PrEParadas, NCT03220152). Participants had a first PK assessment (PK1) 15 days after FHT (estradiol valerate 2-6 mg plus spironolactone 100-200 mg) initiation and then started PrEP (tenofovir disoproxil fumarate 300 mg/emtricitabine 200 mg). A second PK evaluation was performed 12 weeks later (PK2). Blood samples were collected prior and after the directly observed dosing (0, 0.5, 1, 2, 4, 6, 8, and 24 hours). Pharmacokinetic parameters of estradiol, spironolactone, and metabolites were estimated by non-compartmental analysis (Monolix 2021R2, Lixoft®) and compared as geometric mean ratios (GMRs, 90% confidence interval [CI]). RESULTS Among 19 TGW who completed the substudy, median age was 26 years (interquartile range: 23-27.5). Estradiol area under the plasma concentration-time curve (AUCτ) and trough concentrations did not differ between PK1 and PK2 evaluations (GMR [90% CI]: 0.89 [0.76-1.04] and 1.06 [0.94-1.20], respectively). Spironolactone and canrenone AUCτ were statistically lower at PK2 than PK1 (0.76 [0.65-0.89] and 0.85 [0.78-0.94], respectively). Canrenone maximum concentration was also lower at PK2 than PK1 (0.82 [0.74-0.91]). CONCLUSION Estradiol PK was not influenced by PrEP concomitant use. The small differences observed in some spironolactone and canrenone PK parameters should not prevent the concomitant use of estradiol-based FHT and PrEP. TRIAL REGISTRATION This trial (NCT03220152) was registered on July 18, 2017.
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Affiliation(s)
- Vitória Berg Cattani
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil.
| | - Emilia Moreira Jalil
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Leonardo Eksterman
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Thiago Torres
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Sandra Wagner Cardoso
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Cristiane R V Castro
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Laylla Monteiro
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Erin Wilson
- University of California, San Francisco, USA
| | | | | | | | - Beatriz Grinsztejn
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Rita Estrela
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil.
- Faculty of Pharmacy, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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13
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Restar A, Minalga BJ, Quilantang MI, Adamson T, Dusic E, van der Merwe LA, Millet G, Rosadiño D, Laguing T, Lett E, Everhart A, Phillips G, Janamnuaysook R, Seekaew P, Baker K, Ashley F, Wickersham J, Wallace SE, Operario D, Gamarel KE. Mapping Community-Engaged Implementation Strategies with Transgender Scientists, Stakeholders, and Trans-Led Community Organizations. Curr HIV/AIDS Rep 2023; 20:160-169. [PMID: 37012537 PMCID: PMC10071255 DOI: 10.1007/s11904-023-00656-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2023] [Indexed: 04/05/2023]
Abstract
PURPOSE OF REVIEW Pre-exposure prophylaxis (PrEP) represents one of the most effective methods of prevention for HIV, but remains inequitable, leaving many transgender and nonbinary (trans) individuals unable to benefit from this resource. Deploying community-engaged PrEP implementation strategies for trans populations will be crucial for ending the HIV epidemic. RECENT FINDINGS While most PrEP studies have progressed in addressing pertinent research questions about gender-affirming care and PrEP at the biomedical and clinical levels, research on how to best implement gender-affirming PrEP systems at the social, community, and structural levels remains outstanding. The science of community-engaged implementation to build gender-affirming PrEP systems must be more fully developed. Most published PrEP studies with trans people report on outcomes rather than processes, leaving out important lessons learned about how to design, integrate, and implement PrEP in tandem with gender-affirming care. The expertise of trans scientists, stakeholders, and trans-led community organizations is essential to building gender-affirming PrEP systems.
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Affiliation(s)
- Arjee Restar
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.
- Department of Social and Behavioral Sciences, Yale University School of Public Health, New Haven, CT, USA.
| | | | - Ma Irene Quilantang
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Tyler Adamson
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emerson Dusic
- Department of Biostatistics, University of Washington School of Public Health, Seattle, WA, USA
| | - Leigh-Ann van der Merwe
- Social, Health and Empowerment Feminist Collective of Transgender Women of Africa, East London, South Africa
| | - Greg Millet
- The Foundation for AIDS Research, amfAR, amfAR, Washington, D.C, USA
| | | | - Tanya Laguing
- LoveYourself Inc, Manila, Philippines
- DIOSSA Inc, Taguig, Philippines
| | - Elle Lett
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA, USA
| | - Avery Everhart
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Gregory Phillips
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rena Janamnuaysook
- Institute of HIV Research and Innovation, Bangkok, Thailand
- Tangerine Community Health Clinic, Bangkok, Thailand
| | - Pich Seekaew
- Institute of HIV Research and Innovation, Bangkok, Thailand
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Kellan Baker
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Whitman-Walker Institute, Washington, D.C, USA
| | - Florence Ashley
- Faculty of Law and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Jeffrey Wickersham
- Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephaun E Wallace
- Fred Hutchinson Cancer Center, Seattle, WA, USA
- Global Health, University of Washington, Seattle, WA, USA
| | - Don Operario
- Department of Behavioral, Social, and Health Education Sciences, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Kristi E Gamarel
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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14
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Restar AJ, Quilantang MI, Wickersham J, Adia A, Guigayoma J, Bermudez AN, Galárraga O, Flores DD, Cu‐Uvin S, Nazareno J, Operario D, Sison O. Predictors of PrEP awareness, PrEP discussion and interest in long-acting injectable PrEP among Filipina transfeminine adults. J Int AIDS Soc 2023; 26:e26080. [PMID: 37306123 PMCID: PMC10258862 DOI: 10.1002/jia2.26080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/08/2023] [Indexed: 06/13/2023] Open
Abstract
INTRODUCTION Transfeminine adults are impacted by the HIV epidemic in the Philippines, and newly approved modalities of pre-exposure prophylaxis (PrEP), including long-acting injectable (LAI-PrEP), could be beneficial for this group. To inform implementation, we analysed PrEP awareness, discussion and interest in taking LAI-PrEP among Filipina transfeminine adults. METHODS We utilized secondary data from the #ParaSaAtin survey that sampled Filipina transfeminine adults (n = 139) and conducted a series of multivariable logistic regressions with lasso selection to explore factors independently associated with PrEP outcomes, including awareness, discussion with trans friends and interest in LAI-PrEP. RESULTS Overall, 53% of Filipina transfeminine respondents were aware of PrEP, 39% had discussed PrEP with their trans friends and 73% were interested in LAI-PrEP. PrEP awareness was associated with being non-Catholic (p = 0.017), having previously been HIV tested (p = 0.023), discussing HIV services with a provider (p<0.001) and having high HIV knowledge (p = 0.021). Discussing PrEP with friends was associated with older age (p = 0.040), having experienced healthcare discrimination due to transgender identity (p = 0.044), having HIV tested (p = 0.001) and having discussed HIV services with a provider (p < 0.001). Very interested in LAI-PrEP was associated with living in Central Visayas (p = 0.045), having discussed HIV services with a provider (p = 0.001) and having discussed HIV services with a sexual partner (p = 0.008). CONCLUSIONS Implementing LAI-PrEP in the Philippines requires addressing systemic improvements across personal, interpersonal, social and structural levels in healthcare access, including efforts to create healthcare settings and environments with providers who are trained and competent in transgender health and can address the social and structural drivers of trans health inequities, including HIV and barriers to LAI-PrEP.
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Affiliation(s)
- Arjee Javellana Restar
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWashingtonUSA
- Department of Behavioral and Social Sciences, Research Education Institute for Diverse Scholars (REIDS)Yale University School of Public HealthNew HavenConnecticutUSA
- Philippines Health Initiative for Research, Service & Training (PHIRST)Brown University School of Public HealthProvidenceRhode IslandUSA
| | - Ma Irene Quilantang
- Philippines Health Initiative for Research, Service & Training (PHIRST)Brown University School of Public HealthProvidenceRhode IslandUSA
- Department of Behavioral and Social SciencesBrown University School of Public HealthProvidenceRhode IslandUSA
- Department of Behavioral SciencesUniversity of Philippines‐ManilaManilaPhilippines
| | - Jeffrey Wickersham
- Department of Behavioral and Social Sciences, Research Education Institute for Diverse Scholars (REIDS)Yale University School of Public HealthNew HavenConnecticutUSA
- Department of Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Alex Adia
- Philippines Health Initiative for Research, Service & Training (PHIRST)Brown University School of Public HealthProvidenceRhode IslandUSA
- Division of Health Policy and ManagementUniversity of California – Berkeley School of Public HealthBerkeleyCaliforniaUSA
| | - John Guigayoma
- Philippines Health Initiative for Research, Service & Training (PHIRST)Brown University School of Public HealthProvidenceRhode IslandUSA
- Department of Behavioral and Social SciencesBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Amiel Nazer Bermudez
- Philippines Health Initiative for Research, Service & Training (PHIRST)Brown University School of Public HealthProvidenceRhode IslandUSA
- Department of EpidemiologyBrown University School of Public HealthProvidenceRhode IslandUSA
- Department of Epidemiology and BiostatisticsUniversity of Philippines‐ManilaManilaPhilippines
| | - Omar Galárraga
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Dalmacio Dennis Flores
- Department of Behavioral and Social Sciences, Research Education Institute for Diverse Scholars (REIDS)Yale University School of Public HealthNew HavenConnecticutUSA
- Department of Family and Community HealthUniversity of Pennsylvania School of NursingPhiladelphiaPennsylvaniaUSA
| | - Susan Cu‐Uvin
- Philippines Health Initiative for Research, Service & Training (PHIRST)Brown University School of Public HealthProvidenceRhode IslandUSA
- Department of Behavioral and Social SciencesBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Jennifer Nazareno
- Philippines Health Initiative for Research, Service & Training (PHIRST)Brown University School of Public HealthProvidenceRhode IslandUSA
- Department of Behavioral and Social SciencesBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Don Operario
- Philippines Health Initiative for Research, Service & Training (PHIRST)Brown University School of Public HealthProvidenceRhode IslandUSA
- Department of Behavioral, Social, and Health Education SciencesEmory University Rollins School of Public HealthAtlantaGeorgiaUSA
| | - Olivia Sison
- Philippines Health Initiative for Research, Service & Training (PHIRST)Brown University School of Public HealthProvidenceRhode IslandUSA
- Department of EpidemiologyBrown University School of Public HealthProvidenceRhode IslandUSA
- Institute of Clinical Epidemiology, National Institutes of HealthUniversity of Philippines‐ManilaManilaPhilippines
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15
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Subramanian S, Namusoke-Magongo E, Edwards P, Atujuna M, Chimulwa T, Dow D, Jalil E, Torbunde N, Agot K, Arinaitwe I, Beizer J, Chelwa N, Mbalinda SN, Miti S, Mwangwa F. Integrated Health Care Delivery for Adolescents Living with and at Risk of HIV Infection: A Review of Models and Actions for Implementation. AIDS Behav 2023; 27:50-63. [PMID: 35841465 PMCID: PMC9287816 DOI: 10.1007/s10461-022-03787-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2022] [Indexed: 11/02/2022]
Abstract
Integrated service delivery, providing coordinated services in a convenient manner, is important in HIV prevention and treatment for adolescents as they have interconnected health care needs related to HIV care, sexual and reproductive health and disease prevention. This review aimed to (1) identify key components of adolescent-responsive integrated service delivery in low and middle-income countries, (2) describe projects that have implemented integrated models of HIV care for adolescents, and (3) develop action steps to support the implementation of sustainable integrated models. We developed an implementation science-informed conceptual framework for integrated delivery of HIV care to adolescents and applied the framework to summarize key data elements in ten studies or programs across seven countries. Key pillars of the framework included (1) the socioecological perspective, (2) community and health care system linkages, and (3) components of adolescent-focused care. The conceptual framework and action steps outlined can catalyze design, implementation, and optimization of HIV care for adolescents.
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Affiliation(s)
- Sujha Subramanian
- RTI International, 3040 E. Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC, 27709, USA.
| | | | - Patrick Edwards
- RTI International, 3040 E. Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC, 27709, USA
| | - Millicent Atujuna
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | | | - Dorothy Dow
- Duke Global Health Institute, Durham, NC, USA
| | | | | | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | | | - Jenny Beizer
- RTI International, 3040 E. Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC, 27709, USA
| | | | | | - Sam Miti
- Copperbelt University School of Medicine, Ndola, Zambia
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16
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Kuhns LM, Perloff J, Johnson AK, Paul JL, Pleasant K, Evans K, Denson DJ, Gelaude DJ, Bessler PA, Diskin R, Cervantes M, Garofalo R, Hotton AL. A cross-sectional analysis of psychosocial and structural barriers and facilitators associated with PrEP use among a sample of transgender women in Chicago, IL. AIDS Res Ther 2023; 20:24. [PMID: 37085860 PMCID: PMC10122350 DOI: 10.1186/s12981-023-00516-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 04/03/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND Expanding pre-exposure prophylaxis (PrEP) among transgender women in the United States is an important strategy to meet national HIV prevention goals, however self-reported use of PrEP is low in this group. METHODS This study reports the findings of a cross-sectional analysis of the relationship of barriers as well as facilitators to recent PrEP use among transgender women enrolled in an evaluation of the TransLife Care project (Chicago, Illinois), a structural intervention designed to meet basic needs. We computed multivariable prevalence ratios for barriers, facilitators and recent PrEP use, controlling for demographics. RESULTS Findings suggest that psychosocial and structural barriers, including moderate/high alcohol use, stimulant use, and history of incarceration were all positively associated with recent PrEP use among urban transgender women. In addition, a psychosocial facilitator, gender affirmation, was positively associated with recent PrEP use, while, while collective self-esteem, a was negatively associated with it. Finally, common indications for PrEP have high sensitivity, but low specificity and predictive value for identifying those on PrEP. CONCLUSION We conclude that despite a large gap in PrEP use among those with indications, individuals experiencing psychosocial and structural barriers are more likely to use PrEP, and facilitators, such as psychological sense of affirmed gender may support its use. TRIAL REGISTRATION N/A.
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Affiliation(s)
- Lisa M Kuhns
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
- Division of Adolescent and Young Adult Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Judy Perloff
- Chicago House and Social Service Agency, Chicago, IL, USA
| | - Amy K Johnson
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
- Division of Adolescent and Young Adult Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Kevin Pleasant
- Chicago House and Social Service Agency, Chicago, IL, USA
| | - Kaiji Evans
- Chicago House and Social Service Agency, Chicago, IL, USA
| | - Damian J Denson
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Rose Diskin
- Division of Adolescent and Young Adult Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Marbella Cervantes
- Division of Adolescent and Young Adult Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Robert Garofalo
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
- Division of Adolescent and Young Adult Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Anna L Hotton
- Department of Medicine, University of Chicago, Chicago, IL, USA
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17
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Wolfe HL, Drainoni ML, Klasko-Foster L, Fix GM, Siegel J, Mimiaga MJ, Reisner SL, Hughto JM. Structural Equation Modeling of Stigma and HIV Prevention Clinical Services Among Transgender and Gender Diverse Adults: The Mediating Role of Substance Use and HIV Sexual Risk. J Acquir Immune Defic Syndr 2023; 92:300-309. [PMID: 36515898 PMCID: PMC9974738 DOI: 10.1097/qai.0000000000003144] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Transgender and gender diverse (TGD) adults experience high levels of stigma that contributes to elevated substance use and HIV sexual risk behaviors. Despite higher burdens of substance use and HIV compared to cisgender adults, TGD individuals may be less likely to engage in health care to avoid further discrimination. SETTING This analysis included 529 TGD adults in Massachusetts and Rhode Island who were HIV negative or had an unknown HIV serostatus and were purposively sampled between March and August 2019. METHODS We used structural equation modeling to test whether substance use, HIV sexual risk behaviors (ie, condom use, sex work, and multiple partners), and receiving gender-affirming hormone therapy mediate any observed association between TGD-related stigma and utilization of HIV prevention clinical services (ie, HIV prevention programs, PrEP use, and HIV testing). RESULTS Substance use and HIV sexual risk mediated the relationship between TGD-related stigma and utilization of HIV prevention clinical services (β = 0.08; 95% CI = 0.05, 0.17; P = 0.03 and β = 0.26; 95% CI = 0.14 to 0.37; P < 0.001). Having a hormone therapy prescription was not a mediator between TGD-related stigma and HIV prevention clinical services. CONCLUSIONS Future interventions that aim to improve HIV prevention clinical services among TGD adults should consider the impact of TGD-related stigma on participants' substance use and sexual risk behaviors. These efforts require that health care organizations and community organizations make a deliberate investment in the reach and success of interventions and programs.
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Affiliation(s)
- Hill L. Wolfe
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA
| | - Mari-Lynn Drainoni
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA
- Evans Center for Implementation and Improvement Sciences, Boston University, Boston, MA
| | - Lynne Klasko-Foster
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, Rhode Island
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI
| | - Gemmae M. Fix
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Jennifer Siegel
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
- Transgender Health Program, Massachusetts General Hospital, Boston, MA
| | - Matthew J. Mimiaga
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
- The Fenway Institute, Fenway Health, Boston, MA
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA
- Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
- University of California Los Angeles Center for LGBTQ Advocacy, Research & Health, Los Angeles, CA
| | - Sari L. Reisner
- The Fenway Institute, Fenway Health, Boston, MA
- General Medicine, Harvard Medical School, Boston, MA
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Jaclyn M.W. Hughto
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
- The Fenway Institute, Fenway Health, Boston, MA
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18
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Townes A, Pyra M, Smith DK, Babu AS, Williams T, Wiener J, Henny KD, Schneider J. PrEP Use and Adherence among Transgender Persons in Chicago, IL (SHIPP Study, 2014-2018, USA). AIDS Behav 2023; 27:901-908. [PMID: 36094640 PMCID: PMC10374105 DOI: 10.1007/s10461-022-03826-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2022] [Indexed: 11/25/2022]
Abstract
Few studies investigating daily oral preexposure prophylaxis (PrEP) focus on transgender persons. The Sustainable Health Center Implementation PrEP Pilot (SHIPP) Study included a large observational cohort of transgender persons with implications for PrEP in the United States. We examined data from SHIPP's observational cohort and its Medication Adherence Substudy (MAS) to understand adherence among transgender participants in Chicago, IL. We assessed adherence by the proportion of days covered (PDC) for PrEP medication prescriptions, self-reported interview data, and concentrations of intracellular tenofovir diphosphate (TFV-DP) in dried blood spot (DBS) samples. Between 2014 and 2018, there were 510 transgender participants, 349 (68.4%) transgender women and 152 (29.8%) transgender men. Forty-five of these participants were enrolled in the MAS, 31 (68.9%) transgender women and 9 (20.0%) transgender men. By the 3-month follow up, 100% of MAS participants who completed an interview reported taking 4 or more doses of PrEP in the previous week. At 6, 9, and 12 months, taking 4 or more doses in the past week was reported by 81.0%, 94.1%, and 83.3% of participants, respectively. Results from TFV-DP DBS indicated that fewer participants reached the same level of adherence (4 or more doses/week) at clinical visits compared to self-report and even fewer participants reached this level of adherence based on the calculated PDC. Among participants who remained on PrEP throughout the study, DBS adherence levels declined after the first three months. There remains a critical need to develop strategies to address barriers and interventions that support PrEP adherence among transgender people.
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Affiliation(s)
- Ashley Townes
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA. .,Division of HIV Prevention, Centers for Disease Control and Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, 1600 Clifton Road, NE, Mailstop 8-4, 30329, Atlanta, GA, USA.
| | - Maria Pyra
- Howard Brown Health, Chicago, IL, USA.,University of Chicago, Chicago, IL, USA
| | - Dawn K Smith
- Division of HIV Prevention, Centers for Disease Control and Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, 1600 Clifton Road, NE, Mailstop 8-4, 30329, Atlanta, GA, USA
| | | | | | - Jeffrey Wiener
- Division of HIV Prevention, Centers for Disease Control and Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, 1600 Clifton Road, NE, Mailstop 8-4, 30329, Atlanta, GA, USA
| | - Kirk D Henny
- Division of HIV Prevention, Centers for Disease Control and Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, 1600 Clifton Road, NE, Mailstop 8-4, 30329, Atlanta, GA, USA
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19
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Sevelius JM, Castro DA, Warri V, Moreta Avila L, Chakravarty D, Zamudio-Haas S, Kramer K, Monico Klein K, Zack B. Adapting and Implementing an Evidence-Based Reentry Intervention for Incarcerated Transgender Women: Lessons Learned. JOURNAL OF CORRECTIONAL HEALTH CARE 2023; 29:71-80. [PMID: 36595355 PMCID: PMC10162574 DOI: 10.1089/jchc.21.12.0132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Incarceration is a significant public health issue that disproportionately impacts transgender (trans) women, particularly those of color. The cycle of incarceration interacts with high levels of substance use, mental illness, and HIV to produce a high disease burden among trans women, but, to date, there are no published studies of trans-specific reentry support interventions. Informed by the Model of Gender Affirmation, we systematically adapted and pilot tested the evidence-based Project START intervention to create Girlfriends Connect (GC), a reentry support intervention for trans women incarcerated in a county jail. Qualitative interviews with trans women (10 prerelease and 6 postrelease) and community social service providers and jail staff (n = 7) who serve justice-involved transgender women, as well as input from a community advisory board, informed our adaptation. We then conducted a pilot randomized controlled trial (n = 14) and a service implementation project (n = 16) of GC to examine its feasibility and acceptability. Lessons learned include the importance of peer facilitators, facilitated referral to gender-affirming community resources, and obtaining programmatic buy-in from jail staff and administration. Results indicate that GC is feasible and acceptable, and holds promise in improving the health of transgender women reentering the community after a period of incarceration.
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Affiliation(s)
- Jae M. Sevelius
- Center of Excellence for Transgender Health, Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Danielle A. Castro
- Center of Excellence for Transgender Health, Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Vanessa Warri
- Luskin School of Public Affairs, University of California, Los Angeles, Los Angeles, California, USA
| | | | - Deepalika Chakravarty
- Center of Excellence for Transgender Health, Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sophia Zamudio-Haas
- Center of Excellence for Transgender Health, Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | | | - Kate Monico Klein
- Jail Health Services, San Francisco Department of Public Health, San Francisco, California, USA
| | - Barry Zack
- The Bridging Group, Oakland, California, USA
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20
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Lapadula G, Soria A, Modesti M, Vecchi A, Sabbatini F, Monopoli A, Squillace N, Lungu E, Coloma J, Columpsi P, Cristiano V, Bonfanti P. Behavioural survey and street-based HIV and HCV rapid testing programme among transgender sex workers. Sex Transm Infect 2023; 99:41-46. [PMID: 35351815 DOI: 10.1136/sextrans-2021-055270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 03/14/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Transgender women sex workers (TGW-SW) are disproportionally affected by HIV and have reduced access to testing. Moreover, information regarding their behaviours and health needs is scarce. METHODS A behavioural survey and a targeted testing programme in prostitution sites were conducted in Milan and Monza areas. The non-profit organisation 'ALA Milano Onlus' and 'San Gerardo' Hospital (Monza) implemented a mobile HIV testing unit involving a TGW peer educator, four physicians, a counsellor, a psychologist and a cultural mediator. All TGW-SW were offered anonymous HIV and hepatitis C virus (HCV) oral testing and asked to fill a questionnaire on sexual habits, drug abuse, and knowledge and attitudes towards HIV and STDs. RESULTS Between May and July 2017, 130 TGW-SW, predominantly migrants, were contacted during 15 street visits; among them, 78 (60%) were interviewed. HIV and HCV testing were accepted by 53 (42%) and 67 (52%) TGW-SW, respectively. Twenty-five (19.8%) subjects who reported already established HIV infection were not retested. Seven patients received a new diagnosis of HIV, while nobody tested positive for HCV. Overall, HIV prevalence was 13.2% (25% including those with already known HIV infection). Recent arrival in Italy and young age were associated with risk of undiagnosed HIV infection. Inconsistent condom use was commonly reported during commercial sex (27%) and with non-commercial partners (64%). Alcohol and cocaine abuse were common problems which facilitated risky behaviours. CONCLUSIONS Oral rapid HIV and HCV testing for TGW-SW in outreach settings were feasible and acceptable and led to a considerable number of new diagnoses. Interventions tailored to TGW-SW, focused on HIV prevention, testing and engagement in care, are fundamental.
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Affiliation(s)
- Giuseppe Lapadula
- School of Medicine, University of Milan-Bicocca, Monza, Italy .,Clinic of Infectious Diseases, San Gerardo Hospital - ASST Monza, Monza, Italy
| | - Alessandro Soria
- Clinic of Infectious Diseases, San Gerardo Hospital - ASST Monza, Monza, Italy
| | | | | | - Francesca Sabbatini
- Clinic of Infectious Diseases, San Gerardo Hospital - ASST Monza, Monza, Italy
| | | | - Nicola Squillace
- Clinic of Infectious Diseases, San Gerardo Hospital - ASST Monza, Monza, Italy
| | | | | | - Paola Columpsi
- Clinic of Infectious Diseases, San Gerardo Hospital - ASST Monza, Monza, Italy
| | | | - Paolo Bonfanti
- School of Medicine, University of Milan-Bicocca, Monza, Italy.,Clinic of Infectious Diseases, San Gerardo Hospital - ASST Monza, Monza, Italy
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21
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Determinants of Pre-exposure Prophylaxis (PrEP) Implementation in Transgender Populations: A Qualitative Scoping Review. AIDS Behav 2022; 27:1600-1618. [PMID: 36520334 PMCID: PMC9753072 DOI: 10.1007/s10461-022-03943-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 12/23/2022]
Abstract
We conducted a scoping review of contextual factors impeding uptake and adherence to pre-exposure prophylaxis in transgender communities as an in-depth analysis of the transgender population within a previously published systematic review. Using a machine learning screening process, title and abstract screening, and full-text review, the initial systematic review identified 353 articles for analysis. These articles were peer-reviewed, implementation-related studies of PrEP in the U.S. published after 2000. Twenty-two articles were identified in this search as transgender related. An additional eleven articles were identified through citations of these twenty-two articles, resulting in thirty-three articles in the current analysis. These thirty-three articles were qualitatively coded in NVivo using adapted constructs from the Consolidated Framework for Implementation Research as individual codes. Codes were thematically assessed. We point to barriers of implementing PrEP, including lack of intentional dissemination efforts and patience assistance, structural factors, including sex work, racism, and access to gender affirming health care, and lack of provider training. Finally, over 60% of articles lumped cisgender men who have sex with men with trans women. Such articles included sub-samples of transgender individuals that were not representative. We point to areas of growth for the field in this regard.
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22
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Cooper SE, Rosenblatt J, Gulick RM. Barriers to Uptake of Long-Acting Antiretroviral Products for Treatment and Prevention of Human Immunodeficiency Virus (HIV) in High-Income Countries. Clin Infect Dis 2022; 75:S541-S548. [PMID: 36410385 DOI: 10.1093/cid/ciac716] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Long-acting injectable antiretroviral therapy (LAI-ART) for the treatment and prevention of human immunodeficiency virus (HIV) holds great potential to shift treatment paradigms by offering an alternative to daily oral medication. However, significant challenges at the drug, patient, and system levels risk impeding the uptake and implementation of LAI-ART. This review aims to describe the known and anticipated barriers to uptake of LAI-ART in high-income countries, as well as the ongoing research addressing some of these barriers to improve the delivery and uptake of LAI-ART products.
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Affiliation(s)
- Stanley E Cooper
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA
| | - Joshua Rosenblatt
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA
| | - Roy M Gulick
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA
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23
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Bothma R, O'Connor C, Nkusi J, Shiba V, Segale J, Matsebula L, Lawrence JJ, van der Merwe LL, Chersich M, Hill N. Differentiated HIV services for transgender people in four South African districts: population characteristics and HIV care cascade. J Int AIDS Soc 2022; 25 Suppl 5:e25987. [PMID: 36225147 PMCID: PMC9557019 DOI: 10.1002/jia2.25987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 07/30/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Transgender people in South Africa are disproportionately affected by HIV, discrimination and stigma. Access to healthcare and health outcomes are poor. Although integrating gender-affirming healthcare with differentiated HIV prevention, care and treatment services has shown improvement in HIV service uptake and health outcomes among transgender people, evidence is lacking on the implementation of differentiated service delivery models in southern Africa. This article describes a differentiated service delivery model across four South African sites and transgender individuals who access these services. We assess whether hormone therapy (HT) is associated with continued use of pre-exposure prophylaxis (PrEP) and viral load suppression. METHODS In 2019, differentiated healthcare centres for transgender individuals opened in four South African districts, providing gender-affirming healthcare and HIV services at a primary healthcare level. Routine programme data were collected between October 2019 and June 2021. Descriptive statistics summarized patient characteristics and engagement with HIV prevention and treatment services. We conducted a multivariate logistic regression analysis to determine whether HT was associated with viral load suppression and PrEP continued use. RESULTS In the review period, we reached 5636 transgender individuals through peer outreach services; 86% (4829/5636) of them accepted an HIV test and 62% (3535/5636) were linked to clinical services. Among these, 89% (3130/3535) were transgender women, 5% (192/3535) were transgender men and 6% (213/3535) were gender non-conforming individuals. Of those who received an HIV test, 14% (687/4829) tested positive and 91% of those initiated antiretroviral treatment. Viral load suppression was 75% in this cohort. PrEP was accepted by 28% (1165/4142) of those who tested negative. Five percent (161/3535) reported ever receiving HT through the public healthcare system. Service users who received HT were three-fold more likely to achieve viral load suppression. We did not find any association between HT and continued use of PrEP. CONCLUSIONS A differentiated HIV and gender-affirming service delivery model at a primary healthcare level is feasible and can enhance service access in South Africa. HT can improve HIV clinical outcomes for transgender people. As trust is established between the providers and population, uptake of HIV testing and related services may increase further.
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Affiliation(s)
- Rutendo Bothma
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - Cara O'Connor
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - Jolie Nkusi
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - Vusi Shiba
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - Jacob Segale
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - Luyanda Matsebula
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - J. Joseph Lawrence
- United States Agency for International Development/Southern AfricaCity of TshwaneSouth Africa
| | | | - Matthew Chersich
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - Naomi Hill
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
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24
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Fitch C, Haberer JE, Serrano PA, Muñoz A, French AL, Hosek SG. Individual and structural-level Correlates of Pre-exposure Prophylaxis (PrEP) lifetime and current use in a nationwide sample of young sexual and gender minorities. AIDS Behav 2022; 26:3365-3377. [PMID: 35429311 PMCID: PMC9474722 DOI: 10.1007/s10461-022-03656-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2022] [Indexed: 02/03/2023]
Abstract
The objective of this analysis was to describe individual and structural-level factors associated with pre-exposure prophylaxis (PrEP) use among a sample of sexual and gender minorities (SGM) at risk for HIV recruited using limited interaction strategies. SGM (N = 3330), ages 15-34, without HIV enrolled in a nationwide limited interaction cohort study from 2017 to 2020. A baseline cross-sectional single-survey design examined individual and structural-level correlates of PrEP lifetime use and current use using logistic regression. PrEP lifetime use and current use were reported by 31.2% and 23.9%, respectively, of SGM with PrEP data (n = 3077). PrEP use outcomes (lifetime or current use) in cisgender MSM were associated with being over age 18, Black or other race, Hispanic/Latina/x/o ethnicity, being gay, being out to one's healthcare provider, having health insurance, being a college graduate, and having a greater number of PrEP peers. PrEP use outcomes (lifetime use or current use) in transgender/non-binary participants were associated with being over age 24, being Latinx, being transgender vs. non-binary, being assigned male at birth, being out to their healthcare provider, living in the western or northeastern United States, and having more peers on PrEP. More work is needed to address lower PrEP uptake in SGM under 18 and those whose sex risk may be more dynamic (e.g., non-binary, pansexual/queer, and bisexual SGM) and such strategies should consider utilizing peers to provide information and ameliorate structural barriers.
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Affiliation(s)
- Calvin Fitch
- Behavioral Medicine, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, One Bowdoin Square, 7th Floor, 02114, Boston, MA, USA.
- Harvard Medical School, Harvard University, Boston, MA, USA.
| | - Jessica E Haberer
- Harvard Medical School, Harvard University, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Pedro A Serrano
- Department of Research, CORE Center, Chicago, IL, United States
| | - Alejandro Muñoz
- Department of Research, CORE Center, Chicago, IL, United States
| | - Audrey L French
- Division of Infectious Disease, John Stroger Jr Hospital of Cook County, Chicago, Illinois, USA
| | - Sybil G Hosek
- Division of Infectious Disease, John Stroger Jr Hospital of Cook County, Chicago, Illinois, USA
- Department of Psychiatry, John Stroger Jr Hospital of Cook County, Chicago, Illinois, USA
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25
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 537] [Impact Index Per Article: 268.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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Sevelius JM, Dilworth SE, Reback CJ, Chakravarty D, Castro D, Johnson MO, McCree B, Jackson A, Mata RP, Neilands TB. Randomized Controlled Trial of Healthy Divas: A Gender-Affirming, Peer-Delivered Intervention to Improve HIV Care Engagement Among Transgender Women Living With HIV. J Acquir Immune Defic Syndr 2022; 90:508-516. [PMID: 35502891 PMCID: PMC9259040 DOI: 10.1097/qai.0000000000003014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transgender women are disproportionately affected by HIV and are less likely to be optimally engaged in care than other groups because of psychosocial challenges. With community collaboration, we developed Healthy Divas, an individual-level intervention to increase healthcare empowerment and gender affirmation to improve engagement in HIV care. Healthy Divas comprises 6 peer-led individual sessions and one group workshop facilitated by a healthcare provider with expertise in HIV care and transgender health. SETTING/METHODS To test the intervention's efficacy, we conducted a randomized controlled clinical trial in San Francisco and Los Angeles among transgender women living with HIV; control was no intervention. Transgender field staff conducted recruitment. Assessments occurred at baseline and 3, 6, 9, and 12 months postrandomization. The primary outcome was engagement in HIV care, defined as the sum of (1) self-reported HIV care provider visit, past 6 months, (2) knowledge of most recent CD4 count, (3) self-reported antiretroviral therapy adherence ≥90%, and (4) self-reported antiretroviral therapy adherence ≥80%. RESULTS We enrolled 278 participants; almost half (46%) were African American/Black and one-third (33%) were Hispanic/Latina. At 6 months, participants in the intervention arm had over twice the odds of being in a higher HIV care engagement category than those in the control arm (aOR = 2.17; 95% CI: 1.06 to 4.45; P = 0.04); there were no significant study arm differences in the outcome at the other time points. CONCLUSIONS This trial demonstrates the short-term efficacy of an urgently needed behavioral intervention to improve engagement in HIV care among transgender women living with HIV; ongoing intervention may be needed to maintain positive impact over time. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03081559.
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Affiliation(s)
- Jae M. Sevelius
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Center of Excellence for Transgender Health, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Samantha E. Dilworth
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Cathy J. Reback
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Center for HIV Identification, Prevention and Treatment Services, University of California, Los Angeles, CA
| | - Deepalika Chakravarty
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Danielle Castro
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Center of Excellence for Transgender Health, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Mallory O. Johnson
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Breonna McCree
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Center of Excellence for Transgender Health, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Akira Jackson
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
- Center of Excellence for Transgender Health, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Raymond P. Mata
- Friends Community Center, Friends Research Institute, Los Angeles, CA; and
| | - Torsten B. Neilands
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA
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Assessing the Information-Motivation-Behavioral Skills Model to Predict Pre-exposure Prophylaxis Adherence Among Black Men Who have Sex with Men and Transgender Women in a Community Setting in New York City. AIDS Behav 2022; 26:2494-2502. [PMID: 35098392 DOI: 10.1007/s10461-022-03588-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2022] [Indexed: 11/01/2022]
Abstract
The Information-Motivation-Behavioral Skills (IMB) Model has been used to understand adherence to medications and intentions to uptake pre-exposure prophylaxis (PrEP) to prevent HIV infection. In the current study, the IMB Model was used to understand factors that predict adherence to PrEP among a community-based cohort of 204 Black men who have sex with men (MSM) and transgender women (TGW) using structural equation modeling. PrEP motivation was directly associated with PrEP behavioral skills (β = 0.320, p = 0.009), and PrEP behavioral skills were directly associated with PrEP adherence (β = 0.416, p = 0.001). PrEP knowledge and PrEP motivation were not associated with PrEP adherence, directly or indirectly. The analysis identified intervenable factors that predicted PrEP adherence. Screening for motivation and behavioral skills could be used to identify where additional support to improve PrEP adherence is needed, or whether to offer alternative PrEP modalities or delivery strategies.
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Cespedes M, Das M, Hojilla JC, Blumenthal J, Mounzer K, Ramgopal M, Hodge T, Torres TS, Peterson C, Shibase S, Elliott A, Demidont AC, Callaghan L, Watson CC, Carter C, Kintu A, Baeten JM, Ogbuagu O. Proactive strategies to optimize engagement of Black, Hispanic/Latinx, transgender, and nonbinary individuals in a trial of a novel agent for HIV pre-exposure prophylaxis (PrEP). PLoS One 2022; 17:e0267780. [PMID: 35657826 PMCID: PMC9165827 DOI: 10.1371/journal.pone.0267780] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/14/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Black and Hispanic/Latinx cisgender men who have sex with men (MSM), transgender women, transgender men, and gender nonbinary (TGNB) individuals have been historically underrepresented in HIV pre-exposure prophylaxis (PrEP) clinical trials. There is an urgent need for ongoing engagement with communities that have been the most impacted by HIV and diverse representation in clinical trials. Here we describe strategic approaches undertaken in the PURPOSE 2 trial to optimize engagement of underrepresented individuals. METHODS AND RESULTS PURPOSE 2 is an ongoing Phase 3 trial evaluating the safety and efficacy of lenacapavir as PrEP in cisgender MSM and TGNB individuals. In PURPOSE 2, we used a multipronged approach aimed at enriching participation of underrepresented individuals. We conducted a review to identify evidence-informed recommendations from literature, engaged with stakeholders, and established the Global Community Advisory and Accountability Group (GCAG) to represent the needs of the community. Insights from stakeholders and GCAG members resulted in an expansion of the study population to include transgender men, gender nonbinary persons, and adolescents, and evaluation of population-specific outcomes. Feedback from stakeholders and GCAG members also informed investigator and site selection; these were selected based on prior experience working with persons from diverse racial, ethnic and gender identities, and estimates of local HIV incidence. Site selection was also expanded to include community-based clinics with services tailored towards Black, Hispanic/Latinx, and TGNB populations. We established a study-wide recruitment goal of 50% Black MSM and 20% Hispanic/Latinx MSM in US sites and 20% transgender women globally. Site-specific recruitment goals were also developed based on local demographics and HIV incidence. Mandatory trainings included Good Participatory Practice guidelines, gender inclusivity, and antiracism. CONCLUSION While further work is needed to achieve equitable representation, the strategies we describe may serve as a framework for future clinical trials. TRIAL REGISTRATION Clinical Trial Number: NCT04925752.
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Affiliation(s)
- Michelle Cespedes
- Division of Infectious Disease, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Moupali Das
- Gilead Sciences, Foster City, CA, United States of America
| | | | - Jill Blumenthal
- Department of Medicine, University of California San Diego, San Diego, CA, United States of America
| | - Karam Mounzer
- Philadelphia FIGHT Community Health Centers, Philadelphia, PA, United States of America
| | - Moti Ramgopal
- Midway Research Center, Fort Pierce, FL, United States of America
| | - Theo Hodge
- Washington Health Institute, Washington, DC, United States of America
| | - Thiago S. Torres
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Charles Peterson
- Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, IL, United States of America
| | | | - Ayana Elliott
- Gilead Sciences, Foster City, CA, United States of America
| | - A. C. Demidont
- Gilead Sciences, Foster City, CA, United States of America
| | | | | | | | - Alex Kintu
- Gilead Sciences, Foster City, CA, United States of America
| | | | - Onyema Ogbuagu
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, United States of America
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Prevention-effective adherence trajectories among transgender women indicated for PrEP in the United States: a prospective cohort study. Ann Epidemiol 2022; 70:23-31. [PMID: 35398255 PMCID: PMC9167788 DOI: 10.1016/j.annepidem.2022.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/18/2022] [Accepted: 03/30/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Adherence to pre-exposure prophylaxis (PrEP) during periods of PrEP-indication (i.e., prevention-effective adherence) is critical for preventing HIV. We sought to describe factors associated with prevention-effective adherence trajectories among transgender women (TW) to inform PrEP implementation strategies. METHODS Using data from The LITE American Cohort (n = 728), we performed group-based multi-trajectory modeling (GBMTM) to identify clusters of TW with similar trajectories of PrEP adherence and indication, and sociodemographic, biobehavioral, and structural correlates of each trajectory. RESULTS We identified five trajectories: (1) consistent indication/no PrEP (15.3%), (2) initial indication/no PrEP (47.1%), (3) declining indication/discontinued PrEP (9.5%), (4) consistent indication/PrEP adherent (18.5%), and (5) increasing indication/initiated PrEP (9.6%). TW diagnosed with an STI were more likely to follow a consistent indication/no PrEP trajectory compared to consistent indication/PrEP adherent trajectory (adjusted Relative Risk Ratio [aRRR], 2.54; 95% confidence interval [CI], 1.16-5.57). TW who experienced homelessness were more likely to follow PrEP discontinuation and initiation trajectories relative to PrEP adherence (aRRR, 2.71; 95% CI, 1.10-6.70 and 2.83; 95% CI, 1.13-7.05, respectively). CONCLUSIONS Over a quarter of TW followed trajectories suggestive of prevention-effective adherence, while 15% did not initiate PrEP despite consistent indication. Findings highlight missed opportunities for PrEP engagement at STI diagnosis and suggest structural interventions addressing housing instability may improve prevention-effective adherence among TW.
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Tanaudommongkon A, Chaturvedula A, Hendrix CW, Fuchs EJ, Shieh E, Bakshi RP, Marzinke MA. Population pharmacokinetics of tenofovir, emtricitabine and intracellular metabolites in transgender women. Br J Clin Pharmacol 2022; 88:3674-3682. [PMID: 35285974 PMCID: PMC9296590 DOI: 10.1111/bcp.15310] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/07/2022] [Accepted: 03/02/2022] [Indexed: 11/03/2022] Open
Abstract
Aims Transgender women (TGW) have been underrepresented in trials and use gender‐affirming hormonal therapies (GAHT) that may alter renal function by significantly increasing creatinine clearance. Population pharmacokinetic (popPK) models and simulations would aid in understanding potential differences in emtricitabine/tenofovir disproxil fumarate (F/TDF) parent–metabolite concentrations in TGW on GAHT when compared to cisgender men (CGM) not exposed to GAHT. Methods Pharmacokinetic (PK) data from a Phase 1, open‐label clinical trial with directly observed therapy of daily F/TDF consisting of 8 TGW and 8 CGM was utilized for model building. PopPK analysis was performed using nonlinear mixed effects modelling (NONMEM 7.5.0). Covariates of body weight, creatinine clearance, and gender were evaluated. Final models were subjected to Monte Carlo simulations to compare drug exposure following once daily and on‐demand (IPERGAY 2 + 1 + 1) dosing of F/TDF. Results Tenofovir (TFV) and emtricitabine PK were best described by a 2‐compartment model, first‐order absorption/elimination with absorption lag time. Parent models were linked to their metabolites by first order formation and elimination. Creatinine clearance was a significant covariate influencing clearance in both models. Simulations demonstrated that at least 2, weekly 2 + 1 + 1 cycles of on‐demand dosing in TGW on GAHT is necessary for TFV‐diphosphate to reach similar exposure after the initial week of on‐demand dosing in CGM not on GAHT. Conclusion PopPK models of TFV, emtricitabine and intracellular metabolites in TGW were established. Dose simulations revealed that TGW should be treated for at least 2 weeks to have comparable exposures to CGM.
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Affiliation(s)
- Asama Tanaudommongkon
- College of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Ayyappa Chaturvedula
- College of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Craig W Hendrix
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edward J Fuchs
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eugenie Shieh
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rahul P Bakshi
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark A Marzinke
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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31
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Hojilla JC, Hurley LB, Marcus JL, Satre DD, Silverberg MJ, Zaritsky EF, Getahun D, Goodman M, Volk JE. HIV Pre-exposure Prophylaxis Continuum of Care Among Transgender Individuals in an Integrated Health care System. J Acquir Immune Defic Syndr 2022; 89:e30. [PMID: 34723924 PMCID: PMC8837673 DOI: 10.1097/qai.0000000000002853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- J. Carlo Hojilla
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Weill Institute for Neurosciences, Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Leo B. Hurley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Julia L. Marcus
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Derek D. Satre
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Weill Institute for Neurosciences, Department of Psychiatry, University of California, San Francisco, CA, USA
| | | | - Eve F. Zaritsky
- Department of Obstetrics and Gynecology, Kaiser Permanente Oakland Medical Centre, Oakland, CA, USA
| | - Darios Getahun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jonathan E. Volk
- Department of Adult and Family Medicine, Kaiser Permanente San Francisco Medical Centre, San Francisco, CA, USA
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Resnick D, Schapira MM, Andrews ME, Essoka-Lasenberry A, Davis-Voge A, Bauermeister JA, Wood SM. "I Think That I Have a Good Understanding of How to Protect Myself": A Qualitative Study About HIV Risk Perceptions Among Men and Gender Diverse Individuals Who Have Sex With Men. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2022; 34:82-S5. [PMID: 35192391 PMCID: PMC8992390 DOI: 10.1521/aeap.2022.34.1.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
This qualitative study aimed to determine how men and gender diverse individuals who have sex with men describe their perceived risk of HIV and what factors influence this risk assessment. We conducted in-depth, virtual interviews with 18 HIV-negative individuals from Philadelphia, eligible for or taking PrEP. The interviews assessed the participants' understanding of their HIV risk, using thematic analysis to deductively code and extract themes. Three themes emerged: (1) participants expressed both deliberative and affective risk perception before and after sexual encounters; (2) participants linked HIV knowledge to risk perception and stigma; (3) participants connected intrinsic and extrinsic factors to risk perception differently. Participants endorsed low overall risk perception, while also describing moments of high affective risk perception after sexual encounters in which they were not able to implement their preferred prevention strategies. Future research should explore helping individuals transform affective risk perception into empowerment around sexual health.
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Affiliation(s)
- Daniel Resnick
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
- Department of Medicine, Emory University School of Medicine, Atlanta GA
| | - Marilyn M Schapira
- The Center for Health Equity Research and Promotion, Michael J Crescenz VA Medical Center, Philadelphia PA
| | - Mary E. Andrews
- Annenberg School of Communication, the University of Pennsylvania, Philadelphia PA
| | - Amadi Essoka-Lasenberry
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Annet Davis-Voge
- HIV Research Prevention Division, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - José A. Bauermeister
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia PA
| | - Sarah M Wood
- Craig Dalsimer Division of Adolescent Medicine, Children Hospital of Philadelphia, Philadelphia PA
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Daily Marijuana Use Predicts HIV Seroconversion Among Black Men Who Have Sex with Men and Transgender Women in Atlanta, GA. AIDS Behav 2022; 26:2503-2515. [PMID: 35094179 DOI: 10.1007/s10461-022-03598-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 11/01/2022]
Abstract
We evaluated whether different types of substance use predicted HIV seroconversion among a cohort of 449 Black men who have sex with men (MSM) and transgender women (TGW). A community-based sample was recruited in Atlanta, GA between December 2012 and November 2014. Participants completed a survey and were tested for STIs (Chlamydia and gonorrhoeae using urine samples and rectal swabs) at baseline. HIV testing was conducted at 12-months post enrollment. Multivariable binary logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CI) for associations between substance use and HIV seroconversion. By 12-month follow-up, 5.3% (n = 24) of participants seroconverted. In multivariable analyses, daily marijuana use was positively associated with HIV seroconversion (aOR 3.07, 95% CI 1.11-8.48, P = 0.030). HIV incidence was high and daily marijuana use was associated with a more than threefold increased odds of HIV seroconversion among a community-based cohort of Black MSM and TGW.
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Van Gerwen OT, Austin EL, Camino AF, Odom LV, Muzny CA. “It’s behaviors, not identity”: Attitudes and beliefs related to HIV risk and pre-exposure prophylaxis among transgender women in the Southeastern United States. PLoS One 2022; 17:e0262205. [PMID: 35085284 PMCID: PMC8794203 DOI: 10.1371/journal.pone.0262205] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/19/2021] [Indexed: 11/18/2022] Open
Abstract
HIV prevalence is high among transgender women (TGW) in the Southeastern U.S. Uptake of HIV Pre-Exposure Prophylaxis (PrEP) is low among TGW nationwide. We aimed to explore beliefs associated with PrEP among TGW in the Southeastern U.S., framed by the Health Belief Model. HIV-negative TGW ≥18 years old in Alabama participated in virtual focus group discussions. Authors coded and amended transcripts to explore emerging themes. Between July-December 2020, 17 TGW participated in 4 sessions. Mean age was 28.1±8.5 years. Several themes were identified: frustration with conflation of transgender identity and HIV risk, inappropriate transgender representation in PrEP advertising, concerns for interactions between PrEP and hormone therapy, perception that PrEP is meant for cisgender men who have sex with men and limited trans-affirming healthcare. Nuanced messaging is necessary to properly educate and engage TGW in HIV prevention strategies including PrEP given the diversity of this population.
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Affiliation(s)
- Olivia T. Van Gerwen
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- * E-mail:
| | - Erika L. Austin
- Department of Biostatistics, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama, United States of America
| | - Andres F. Camino
- University of Alabama School of Medicine, Birmingham, Alabama, United States of America
| | - L. Victoria Odom
- University of Alabama School of Medicine, Birmingham, Alabama, United States of America
| | - Christina A. Muzny
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
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Howson A, Mutschler B, McCrea A. Designing and Evaluating a Gender-Affirming Educational Initiative for Optimal HIV Care: An Intrinsic Case Study. Transgend Health 2022; 6:296-301. [PMID: 34993302 DOI: 10.1089/trgh.2020.0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Gender-affirming care that integrates transgender and gender nonconforming (TGNC)-related and/or transition-related health care needs is an effective mechanism to increase the number of TGNC patients being screened for HIV and linked to HIV services. Methods: Evaluation of a gender-affirming education initiative to help clinicians in one clinic provides better care for TGNC patients. Results: Processes and factors that support the effective implementation of a gender-affirming clinical environment include (1) establishing credibility within the local TGNC community; (2) the critical role played by a patient navigator; and (3) awareness of the lived experience of being TGNC. Participating in the education initiative boosted team motivation, improved knowledge and competence, and provided opportunities for training nonclinical staff. Conclusion: This practice assessment interview offers a unique window into the impact of an education initiative on the effective implementation of a gender-affirming clinical environment.
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Affiliation(s)
| | - Brett Mutschler
- Annenberg Center for Health Sciences at Eisenhower, Rancho Mirage, California, USA
| | - Andrew McCrea
- Annenberg Center for Health Sciences at Eisenhower, Rancho Mirage, California, USA
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Exploring barriers and facilitators to PrEP use among transgender women in two urban areas: implications for messaging and communication. BMC Public Health 2022; 22:17. [PMID: 34991548 PMCID: PMC8740429 DOI: 10.1186/s12889-021-12425-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 12/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Trans women are at increased risk for HIV infection yet are less likely to use pre-exposure prophylaxis (PrEP) medication as a preventive measure. PrEP messaging and marketing has focused on men who have sex with men (MSM) or included trans women as a subset of MSM, ignoring the potential barriers to PrEP use unique to trans women. Little is known about how this group conceptualizes PrEP, what knowledge gaps still exist, and how trans women believe PrEP should be communicated to increase use. METHODS This qualitative study conducted focus groups (n = 5) in Philadelphia and Sacramento with trans women to assess these issues. RESULTS Twelve sub-themes were found related to five main domains, including PrEP knowledge, benefits, barriers, community-related considerations, and messaging/marketing. Findings indicate that knowledge of PrEP is still low and beliefs about PrEP's effects on hormone use persist. Most importantly, participants voiced a demand for culturally appropriate trans-specific messages in HIV prevention interventions and communication. CONCLUSIONS Without acknowledging specific barriers to PrEP uptake among transgender women separate from those of MSM and incorporating gender affirmation into PrEP education, simply knowing PrEP is available may not motivate trans women to use PrEP. This has important implications for future efforts to communicate about PrEP with trans women.
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Lacombe-Duncan A, Berringer KR, Green J, Jacobs A, Hamdi A. “I do the she and her”: A qualitative exploration of HIV care providers’ considerations of trans women in gender-specific HIV care. WOMEN'S HEALTH 2022; 18:17455057221083809. [PMID: 35311400 PMCID: PMC8935587 DOI: 10.1177/17455057221083809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objectives: Women of all genders, including cisgender (cis) and transgender (trans) women, experience social and structural drivers of HIV inequities and pervasive barriers to HIV care. Yet, little is known about how HIV care providers address gender diversity in health care. Through a critical feminist lens informed by intersectionality theory, medical anthropology, and critical sociology, we explored (1) how do HIV care providers describe women living with HIV’s care needs and barriers; (2) what are their perspectives on optimal HIV care for women; and (3) to what extent do these conceptualizations include/exclude trans women. Methods: Utilizing a community-based exploratory qualitative study design, we conducted 60–90 minute semi-structured individual interviews from March 2019–April 2020 with eight HIV care providers (n = 4 social service providers; n = 4 physicians) practicing across seven counties representative of rural, suburban, and urban Michigan, United States. Data were analyzed utilizing a reflexive thematic approach. Results: Three overarching themes emerged: (1) Emphasis on (different) clinical needs: key considerations in cis and trans women’s HIV care; (2) Recognition of the structural: barriers to HIV care affecting women of all genders; and (3) Proposed solutions: piecing together individual, social, and organizational interventions to increase access to HIV care that may benefit women living with HIV of all genders but are disproportionately framed as being for cis women. While HIV care providers recognized both cis and trans women living with HIV’s clinical care needs and structural barriers to care, they rarely envisioned optimal HIV care inclusive of gender affirmation and structural interventions. Conclusions: Findings suggest that HIV care providers can avoid reducing gender to biology and making assumptions about reproductive care needs, endocrinological care needs, caregiving responsibilities, and other life circumstances; provide gender-affirming medical care; and address structural barriers to HIV care to enhance intersectional and structurally focused gender-affirming—that is, trans-inclusive—women-centered HIV care.
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Affiliation(s)
| | - Kathryn R Berringer
- School of Social Work, University of Michigan, Ann Arbor, MI, USA
- Department of Anthropology, University of Michigan, Ann Arbor, MI, USA
| | | | - Amy Jacobs
- Michigan HIV/AIDS Treatment Program, Michigan Medicine, Ann Arbor, MI, USA
| | - Amy Hamdi
- Michigan HIV/AIDS Council (MHAC), Lansing, MI, USA
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Sevelius JM, Glidden DV, Deutsch M, Welborn L, Contreras A, Salinas A, Venegas L, Grant RM. Uptake, Retention, and Adherence to Pre-exposure Prophylaxis (PrEP) in TRIUMPH: A Peer-Led PrEP Demonstration Project for Transgender Communities in Oakland and Sacramento, California. J Acquir Immune Defic Syndr 2021; 88:S27-S38. [PMID: 34757990 PMCID: PMC8579996 DOI: 10.1097/qai.0000000000002808] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND TRIUMPH (Trans Research-Informed communities United in Mobilization for the Prevention of HIV) was a community-led, transgender-specific pre-exposure prophylaxis (PrEP) demonstration project at 2 community-based clinical sites in California. TRIUMPH used peer health education, community mobilization, and clinical integration of PrEP with hormone therapy to promote PrEP knowledge and acceptability. The goal of this study was to evaluate PrEP uptake, retention, and adherence among TRIUMPH participants and examine site-based differences. METHODS Eligible participants were adult transgender and gender diverse people interested in PrEP. Participants were seen at baseline and at 1, 3, 6, 9, and 12 months for PrEP provision, clinical visits, and HIV testing. PrEP uptake was defined as dispensation of PrEP, PrEP retention was defined as proportion of expected visits completed among those who initiated PrEP, and PrEP adherence was assessed by measuring tenofovir diphosphate concentrations in dried blood spots. Logistic regression models quantified the association of variables with PrEP outcomes. RESULTS TRIUMPH enrolled 185 participants; the median age was 28 years (interquartile range: 23-35), 7% was Black, and 58% was Latinx. PrEP uptake was as follows: 78% in Oakland and 98% in Sacramento; 91% among trans women, 96% among trans men, and 70% among nonbinary participants. Almost half (47%) rarely/never believed about HIV, and 42% reported condomless sex act in the past 3 months. Participants who reported higher numbers of sex partners were more likely to be retained and adherent; other predictors of adherence included not having a primary partner and not experiencing violence in the past 3 months. CONCLUSIONS This community-led, trans-specific PrEP demonstration project documents high levels of PrEP initiation in a young transgender and gender diverse cohort at risk of HIV acquisition.
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Wilson EC, Turner CM, Sanz-Rodriguez C, Arayasirikul S, Gagliano J, Woods T, Palafox E, Halfin J, Martinez L, Makoni B, Eskman Z, Lin R, Rodriguez E, Rapues J, Pardo S, Liu A. Expanding the Pie-Differentiated PrEP Delivery Models to Improve PrEP Uptake in the San Francisco Bay Area. J Acquir Immune Defic Syndr 2021; 88:S39-S48. [PMID: 34757991 PMCID: PMC8579985 DOI: 10.1097/qai.0000000000002809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) uptake among trans people to date has been low. Recommendations implemented in San Francisco to offer PrEP with feminizing hormones have not led to improvement of PrEP uptake in trans communities. New delivery models may be needed. The aim of this study was to examine whether a PrEP-only clinic was more likely to serve trans people at highest risk of HIV than trans-affirming primary care clinics. METHODS Participants were recruited between 2017 and 2019 as part of a PrEP demonstration project in the San Francisco Bay Area. Survey data including sociodemographics, HIV-related risk behavior, barriers to PrEP, and self-reported PrEP adherence were collected at baseline, 3 months, and 6 months for all participants. Bivariable Poisson regression models were used to examine differences between participants in the primary care clinics and PrEP-only clinic delivered to participants. RESULTS Baseline survey data were collected from 153 participants. Those with a higher number of sexual partners were significantly more likely to use the PrEP-only clinic rather than the primary care clinics. Participants with higher perceived HIV risk and those who engaged in sex work were also more likely to use the PrEP-only clinic compared with the primary care clinic. Medical mistrust was higher at baseline among participants of the PrEP-only clinic. PrEP adherence was not significantly different by delivery model. Few participants identified PrEP barriers, such as interactions with feminizing hormones, to be determinants of PrEP uptake. CONCLUSIONS A PrEP-only delivery model could improve PrEP uptake and may better meet the needs of trans people who could most benefit from PrEP.
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Affiliation(s)
- Erin C. Wilson
- Center for Public Health Research, Trans Research Unit for Equity, San Francisco Department of Public Health, San Francisco, CA
| | - Caitlin M. Turner
- Center for Public Health Research, Trans Research Unit for Equity, San Francisco Department of Public Health, San Francisco, CA
| | - Christina Sanz-Rodriguez
- Center for Public Health Research, Trans Research Unit for Equity, San Francisco Department of Public Health, San Francisco, CA
| | - Sean Arayasirikul
- Center for Public Health Research, Trans Research Unit for Equity, San Francisco Department of Public Health, San Francisco, CA
| | - Jayne Gagliano
- Center for Public Health Research, Trans Research Unit for Equity, San Francisco Department of Public Health, San Francisco, CA
| | - Tiffany Woods
- TransVision Program, Tri-City Health Center, Fremont, CA
| | - Erika Palafox
- TransVision Program, Tri-City Health Center, Fremont, CA
| | - Janet Halfin
- TransVision Program, Tri-City Health Center, Fremont, CA
| | | | - Bessa Makoni
- TransVision Program, Tri-City Health Center, Fremont, CA
| | - Zebediah Eskman
- Asian and Pacific Islander Wellness Center, San Francisco, CA
| | - Royce Lin
- Trans Tuesdays, Tom Waddell Urban Health Center, San Francisco, CA
| | | | - Jenna Rapues
- San Francisco Department of Public Health, San Francisco, CA; and
| | - Seth Pardo
- San Francisco Department of Public Health, San Francisco, CA; and
| | - Albert Liu
- Bridge HIV, San Francisco Department of Public Health, San Francisco, CA
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Stutterheim SE, van Dijk M, Wang H, Jonas KJ. The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis. PLoS One 2021; 16:e0260063. [PMID: 34851961 PMCID: PMC8635361 DOI: 10.1371/journal.pone.0260063] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 11/02/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction Transgender individuals are at risk for HIV. HIV risks are dynamic and there have been substantial changes in HIV prevention (e.g., pre-exposure prophylaxis [PrEP]). It is thus time to revisit HIV prevalence and burden among transgender individuals. The objective of this systematic review and meta-analysis was thus to examine worldwide prevalence and burden of HIV over the course of the epidemic among trans feminine and trans masculine individuals. Methods We conducted an updated systematic review by searching PsycINFO, PubMed, Web of Science, and Google Scholar, for studies of any research design published in in a peer-reviewed journal in any language that reported HIV prevalence among transgender individuals published between January 2000 and January 2019. Two independent reviewers extracted the data and assessed methodological quality. We then conducted a meta-analysis, using random-effects modelling, to ascertain standardized prevalence and the relative burden of HIV carried by transgender individuals by country and year of data collection, and then by geographic region. We additionally explored the impact of sampling methods and pre-exposure prophylaxis (PrEP). Results Based on 98 studies, overall standardized HIV prevalence over the course of the epidemic, based on weights from each country by year, was 19.9% (95% CI 14.7% - 25.1%) for trans feminine individuals (n = 48,604) and 2.56% (95% CI 0.0% - 5.9%) for trans masculine individuals (n = 6460). Overall OR for HIV infection, compared with individuals over age 15, was 66.0 (95% CI 51.4–84.8) for trans feminine individuals and 6.8 (95% CI 3.6–13.1) for trans masculine individuals. Prevalence varied by geographic region (13.5% - 29.9%) and sampling method (5.4% - 37.8%). Lastly, PrEP effects on prevalence could not be established. Conclusion Trans feminine and trans masculine individuals are disproportionately burdened by HIV. Their unique prevention and care needs should be comprehensively addressed. Future research should further investigate the impact of sampling methods on HIV prevalence, and monitor the potential impact of PrEP.
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Affiliation(s)
- Sarah E. Stutterheim
- Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
- * E-mail:
| | - Mart van Dijk
- Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Haoyi Wang
- Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Kai J. Jonas
- Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
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Transgender Women's Barriers, Facilitators, and Preferences on Tailored Injection Delivery Strategies to Administer Long-Acting Injectable Cabotegravir (CAB-LA) for HIV Pre-exposure Prophylaxis (PrEP). AIDS Behav 2021; 25:4180-4192. [PMID: 34216284 PMCID: PMC8254438 DOI: 10.1007/s10461-021-03357-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 12/05/2022]
Abstract
Long-acting injectable cabotegravir (CAB-LA) is in advanced stages of clinical trials. Under the standard protocol, CAB-LA is injected into the gluteal muscle by a healthcare provider every eight weeks. To explore transgender women’s barriers and facilitators to tailored delivery strategies—including self-injection and injection in “drop-in” centers—we completed in-depth interviews with N = 15 transgender women in New York City. Participants endorsed the alternative delivery methods and the corresponding features we proposed, and expressed likes and dislikes about each. These fell into the following categories: competence (e.g., the person delivering CAB-LA must have skills to do so), convenience (e.g., CAB-LA must be easy to obtain), and privacy or fear of judgement (e.g., participants did not want to feel judged for using CAB-LA by providers or other service consumers). Findings suggest the need to offer CAB-LA to transgender women through multiple delivery protocols.
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Mabire X, Robin-Radier S, Ferraz D, Preau M. FOREST protocol: a qualitative study exploring health and sexuality of transmasculine individuals in France. BMJ Open 2021; 11:e052748. [PMID: 34848520 PMCID: PMC8634350 DOI: 10.1136/bmjopen-2021-052748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 11/03/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION While current research on sexuality and health often explores sexual behaviours among heterosexual and gay cisgender individuals, little is known about the sexualities of transgender people, especially transmasculine people. When data are available, sexual health is often reduced to risk exposure, not considering in detail social context and determinants that could contribute to a more comprehensive approach, such as general health, class, race, exposure to violence or social representations. Recognising this gap, identified in both national (French) and international scientific literature, this study aims to explore the sexual health of transmasculine people, employing an intersectional approach and considering both positive and negative health determinants. METHODS This 2-year research based in the disciplinary field of social psychology, with a gender perspective, and will apply qualitative methods. We adopt a community-based research approach, integrating one university and one community-based organisation in the coordination of the study. In a triangulation perspective, two rounds of semistructured interviews will be performed with key informants (medical practitioners, community-based support services workers, etc) and with people self-identifying as transmasculine. Focus groups will complement data collection. ETHICS AND DISSEMINATION FOREST protocol was approved by the Comité d'Évaluation Éthique (CEEI) de l'Institut National de la Santé Et de la Recherche Médicale (CEEI/International Review Board 00003888). The research adopts the principles of open science, and findings will be published assuring participants' confidentiality. Informative flyers and videos will be elaborated to communicate study findings to participants, stakeholders and the transcommunities at large, and data will be stored in lasting archives.
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Affiliation(s)
- Xavier Mabire
- PHASE (Psychology of Health, Aging and Sport Examination), University of Lausanne Faculty of Social and Political Science, Lausanne, Vaud, Switzerland
- UMR 1296 "Radiations: Défense, Santé, Environnement", Université Lyon 2, Lyon, Auvergne-Rhône-Alpes, France
| | - Suzanne Robin-Radier
- UMR 1296 "Radiations: Défense, Santé, Environnement", Université Lyon 2, Lyon, Auvergne-Rhône-Alpes, France
- Community-Based Organization, OUTrans NGO, Paris, Île-de-France, France
| | - Dulce Ferraz
- PHASE (Psychology of Health, Aging and Sport Examination), University of Lausanne Faculty of Social and Political Science, Lausanne, Vaud, Switzerland
- UMR 1296 "Radiations: Défense, Santé, Environnement", Université Lyon 2, Lyon, Auvergne-Rhône-Alpes, France
- Escola FIOCRUZ de Governo, Fundação Oswaldo Cruz, Brasília, Brazil
| | - Marie Preau
- UMR 1296 "Radiations: Défense, Santé, Environnement", Université Lyon 2, Lyon, Auvergne-Rhône-Alpes, France
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Goldenberg T, Gamarel KE, Reisner SL, Jadwin-Cakmak L, Harper GW. Gender Affirmation as a Source of Resilience for Addressing Stigmatizing Healthcare Experiences of Transgender Youth of Color. Ann Behav Med 2021; 55:1168-1183. [PMID: 33761531 PMCID: PMC8601040 DOI: 10.1093/abm/kaab011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Transgender and other gender diverse (TGD) youth of color experience stigma within healthcare. Gender affirmation can be a resilience resource; however, little is known about gender affirmation within healthcare. PURPOSE This study explores TGD youth of color's experiences of stigma and gender affirmation across the entire healthcare experience and their role on motivation to seek care. METHODS In 2015, cross-sectional surveys and individual in-depth interviews were conducted among 187 TGD youth ages 16-24 living in 14 U.S. cities. Analyses followed a mixed-methods design whereby 33 participants were purposively selected for a qualitative phenomenological analysis based on quantitatively reported gender affirmation needs. Subsequent quantitative analyses examined how healthcare use differed by access to gender affirmation. RESULTS Participants qualitatively described experiencing stigma across multiple healthcare settings (e.g., primary care, emergency care, medical gender affirmation), including before (finding providers, scheduling), during (waiting rooms, provider interactions), and after (pharmacy) healthcare visits. Participants who quantitatively reported access to gender-affirming healthcare still described negative healthcare experiences, either because they accessed multiple healthcare services or because of prior negative experiences. Stigma and gender affirmation (both inside and outside of healthcare) influenced motivation to seek care, with variation depending on the type of care. Quantitative analyses confirmed these findings; access to gender affirmation differed for participants who delayed primary care vs. those who did not, but did not vary based on participants' use of medical gender affirmation. CONCLUSIONS Findings highlight the importance of promoting gender-affirming healthcare environments to increase access to care for TGD youth of color.
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Affiliation(s)
- Tamar Goldenberg
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kristi E Gamarel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Center for Sexuality and Health Disparities, University of Michigan, Ann Arbor, MI, USA
| | - Sari L Reisner
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Laura Jadwin-Cakmak
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Gary W Harper
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
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Malone J, Reisner SL, Cooney EE, Poteat T, Cannon CM, Schneider JS, Radix A, Mayer KH, Haw JS, Althoff KN, Wawrzyniak AJ, Beyrer C, Wirtz AL. Perceived HIV Acquisition Risk and Low Uptake of PrEP Among a Cohort of Transgender Women With PrEP Indication in the Eastern and Southern United States. J Acquir Immune Defic Syndr 2021. [PMID: 34397742 DOI: 10.1097/qai.0000000000002726]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Preexposure prophylaxis (PrEP) is effective in preventing HIV among adherent users. However, PrEP uptake among transgender women is low, and current prescribing guidelines from the Centers for Disease Control and Prevention (CDC) are not specific to transgender women. Self-perceived risk of HIV among those who are PrEP-indicated is not well understood. METHODS This cross-sectional analysis included 1293 transgender women screened at baseline from March 2018 to May 2020 for a multisite, prospective cohort study. We compared the prevalence of PrEP indication using current CDC prescribing criteria versus transgender women-specific criteria developed by study investigators with community input. We identified factors associated with study-specific PrEP indication and factors associated with self-perceived low to no HIV risk among those who were PrEP-indicated. We also calculated descriptive statistics to depict the PrEP care continuum. RESULTS PrEP indication prevalence using transgender women-specific criteria was 47% (611), 155 more than who were identified using the CDC criteria. Eighty-three percent were aware of PrEP, among whom 38% had ever used PrEP. Among PrEP ever users, 63% were using PrEP at the time of the study. There were 66% of current PrEP users who reported 100% adherence within the previous 7 days. Among those who were PrEP-indicated, 13% were using and adherent to PrEP at the time of the study. More than half (55%) of PrEP-indicated participants had low or no self-perceived HIV risk. CONCLUSIONS These findings suggest that further guidance is needed for health care providers in prescribing PrEP to transgender women. Greater uptake and adherence are also needed for optimal effectiveness.
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Affiliation(s)
- Jowanna Malone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sari L Reisner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
- Division of Endocrinology, Diabetes & Hypertension, Brigham and Women's Hospital, Boston, MA
| | - Erin E Cooney
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC
| | | | | | - Asa Radix
- School of Medicine, New York University, New York, NY
| | - Kenneth H Mayer
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
- Fenway Community Health Center, The Fenway Institute, Boston, MA
| | - J Sonya Haw
- Division of Endocrinology, Metabolism, and Lipids, School of Medicine, Emory University, Atlanta, GA
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Chris Beyrer
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrea L Wirtz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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D'Avanzo PA, Bass SB, Kelly PJ, Brajuha J, Gutierrez-Mock L, Sevelius J. Community Belonging and Attitudes Towards HIV Pre-Exposure Prophylaxis (PrEP) Among Transgender Women. AIDS Behav 2021; 25:2728-2742. [PMID: 33575901 DOI: 10.1007/s10461-021-03183-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 11/26/2022]
Abstract
For transgender (trans) women, community belonging may play an important role in shaping perceptions of HIV Pre-exposure Prophylaxis (PrEP). A cluster analysis was performed using data obtained from a survey administered to 128 trans women residing in Philadelphia, PA and the San Francisco Bay area, CA. Six items assessing feelings of community belongingness among trans women produced three distinct clusters. Associations were examined between cluster membership and perceptual items including beliefs about PrEP, experiences with healthcare, patient self-advocacy, and perceived trusted sources for PrEP information. Clusters were demographically comparable apart from age. There were significant differences noted between trust in various communication channels and perceptions of PrEP; the least community-connected cluster had less trust and more negative perceptions of PrEP. Analyses suggest that psychographic differences exist based on perceived community belongingness in this population, and this in turn may be consequential in determining how information about PrEP is communicated and diffused to trans women for whom PrEP may be indicated.
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Affiliation(s)
- Paul A D'Avanzo
- Department of Social and Behavioral Sciences, Temple University College of Public Health, Philadelphia, PA, USA.
- Risk Communication Laboratory, Temple University College of Public Health, Philadelphia, PA, USA.
| | - Sarah Bauerle Bass
- Department of Social and Behavioral Sciences, Temple University College of Public Health, Philadelphia, PA, USA
- Risk Communication Laboratory, Temple University College of Public Health, Philadelphia, PA, USA
| | - Patrick J Kelly
- Department of Social and Behavioral Sciences, Temple University College of Public Health, Philadelphia, PA, USA
- Risk Communication Laboratory, Temple University College of Public Health, Philadelphia, PA, USA
| | - Jesse Brajuha
- Risk Communication Laboratory, Temple University College of Public Health, Philadelphia, PA, USA
| | - Luis Gutierrez-Mock
- Center of Excellence for Transgender Health, University of California, San Francisco, San Francisco, CA, USA
| | - Jae Sevelius
- Center of Excellence for Transgender Health, University of California, San Francisco, San Francisco, CA, USA
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Lacombe-Duncan A, Kia H, Logie CH, Todd KP, Persad Y, Leblanc G, Nation K, Scheim AI, Lyons T, Horemans C, Loutfy M. A qualitative exploration of barriers to HIV prevention, treatment and support: Perspectives of transgender women and service providers. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:e33-e46. [PMID: 33237600 DOI: 10.1111/hsc.13234] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/14/2020] [Accepted: 10/24/2020] [Indexed: 06/11/2023]
Abstract
Transgender (trans) women experience barriers to access to HIV care, which result in their lower engagement in HIV prevention, treatment and support relative to cisgender people living with HIV. Studies of trans women's barriers to HIV care have predominantly focused on perspectives of trans women, while barriers are most often described at provider, organisation and/or systems levels. Comparing perspectives of trans women and service providers may promote a shared vision for achieving health equity. Thus, this qualitative study utilised focus groups and semi-structured interviews conducted 2018-2019 to understand barriers and facilitators to HIV care from the perspectives of trans women (n = 26) and service providers (n = 10). Barriers endorsed by both groups included: (a) anticipated and enacted stigma and discrimination in the provision of direct care, (b) lack of provider knowledge of HIV care needs for trans women, (c) absence of trans-specific services/organisations and (d) cisnormativity in sexual healthcare. Facilitators included: (a) provision of trans-positive trauma-informed care, (b) autonomy and choice for trans women in selecting sexual health services and (c) models for trans-affirming systems change. Each theme had significant overlap, yet nuanced perspective, between trans women and service providers. Specific recommendations to improve HIV care access for trans women are discussed. These recommendations can be used by administrators and service providers alike to work collaboratively with trans women to reduce barriers and facilitators to HIV care and ultimately to achieve health equity for trans women.
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Affiliation(s)
- Ashley Lacombe-Duncan
- School of Social Work, University of Michigan, Ann Arbor, MI, USA
- Center for Sexuality and Health Disparities, University of Michigan, Ann Arbor, MI, USA
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Hannah Kia
- School of Social Work, University of British Columbia, Vancouver, BC, Canada
| | - Carmen H Logie
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Kieran P Todd
- Center for Sexuality and Health Disparities, University of Michigan, Ann Arbor, MI, USA
| | - Yasmeen Persad
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Gabrielle Leblanc
- Action Santé Travesti(e)s & Transsexuel(le)s du Québec (ASTT(E)Q), Montréal, Canada
| | - Kelendria Nation
- Prism Education Series, Vancouver Coastal Health, Vancouver, BC, Canada
| | - Ayden I Scheim
- Epidemiology and Biostatistics, Drexel Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Tara Lyons
- Department of Criminology, Kwantlen Polytechnic University, Vancouver, BC, Canada
- Center for Gender & Sexual Health Equity (CGSHE), Vancouver, BC, Canada
| | | | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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del Río‐González AM, Lameiras‐Fernández M, Modrakovic D, Aguayo‐Romero R, Glickman C, Bowleg L, Zea MC. Global scoping review of HIV prevention research with transgender people: Transcending from trans-subsumed to trans-centred research. J Int AIDS Soc 2021; 24:e25786. [PMID: 34473421 PMCID: PMC8412127 DOI: 10.1002/jia2.25786] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 07/19/2021] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Globally, transgender populations are disproportionally impacted by HIV and effective HIV prevention interventions targeting these populations are critically needed. Such interventions require research focused on the specific needs and experiences of transgender people. This methodological review aims to determine the extent to which HIV prevention research has included transgender participants by subsuming them into non-transgender populations, or by centring them either in comparison with other groups or as the sole focus of research. METHODS We searched five electronic databases (e.g. SCOPUS) for empirical studies that focused on HIV prevention and included transgender participants, published through 31 December 2020. For each study, we extracted information on: (a) types of inclusion of transgender participants; (b) total sample size and number/percentage of transgender participants; (c) country(ies) where study was conducted; (d) HIV research topics; (e) methods (i.e. quantitative, qualitative or mixed-methods research) and (f) gender identity of transgender participants. RESULTS AND DISCUSSION Of 667 HIV prevention studies included in the review, 38.5% subsumed transgender participants into cisgender populations (most frequently combining transgender women with cisgender men who have sex with men), 20.4% compared transgender and cisgender participants and 41.1% focused exclusively on transgender populations. Our global scoping review also revealed that these three types of transgender inclusion in HIV prevention research vary greatly over time, place and thematic areas. Transgender women are the focus of the majority of reviewed studies, whereas transgender men and gender expansive people are rarely included as participants. CONCLUSIONS Inclusion of transgender persons as participants in HIV prevention research has significantly increased, particularly in the last decade. Further research centred on transgender participants and their experiences are needed to develop effective HIV prevention interventions for transgender populations. We advocate for HIV prevention research to move from subsuming transgender people, to trans-centred research that asks questions that focus on their specific needs and experiences. We provide recommendations to move from trans-subsumed to trans-centred HIV prevention research.
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Affiliation(s)
- Ana María del Río‐González
- Department of Psychological and Brain SciencesThe George Washington UniversityWashingtonDistrict of ColumbiaUSA
| | | | - Djordje Modrakovic
- Department of Psychological and Brain SciencesThe George Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Rodrigo Aguayo‐Romero
- Brigham and Women's Hospital/Harvard Medical School/The Fenway InstituteBostonMassachusettsUSA
| | - Courtney Glickman
- Department of Psychological and Brain SciencesThe George Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Lisa Bowleg
- Department of Psychological and Brain SciencesThe George Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Maria Cecilia Zea
- Department of Psychological and Brain SciencesThe George Washington UniversityWashingtonDistrict of ColumbiaUSA
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Malone J, Reisner SL, Cooney E, Poteat T, Cannon CM, Schneider J, Radix A, Mayer KH, Haw JS, Althoff KN, Wawrzyniak AJ, Beyrer C, Wirtz AL. Perceived HIV Acquisition Risk and Low Uptake of PrEP Among a Cohort of Transgender Women With PrEP Indication in the Eastern and Southern United States. J Acquir Immune Defic Syndr 2021; 88:10-18. [PMID: 34397742 PMCID: PMC8371736 DOI: 10.1097/qai.0000000000002726] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/03/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Preexposure prophylaxis (PrEP) is effective in preventing HIV among adherent users. However, PrEP uptake among transgender women is low, and current prescribing guidelines from the Centers for Disease Control and Prevention (CDC) are not specific to transgender women. Self-perceived risk of HIV among those who are PrEP-indicated is not well understood. METHODS This cross-sectional analysis included 1293 transgender women screened at baseline from March 2018 to May 2020 for a multisite, prospective cohort study. We compared the prevalence of PrEP indication using current CDC prescribing criteria versus transgender women-specific criteria developed by study investigators with community input. We identified factors associated with study-specific PrEP indication and factors associated with self-perceived low to no HIV risk among those who were PrEP-indicated. We also calculated descriptive statistics to depict the PrEP care continuum. RESULTS PrEP indication prevalence using transgender women-specific criteria was 47% (611), 155 more than who were identified using the CDC criteria. Eighty-three percent were aware of PrEP, among whom 38% had ever used PrEP. Among PrEP ever users, 63% were using PrEP at the time of the study. There were 66% of current PrEP users who reported 100% adherence within the previous 7 days. Among those who were PrEP-indicated, 13% were using and adherent to PrEP at the time of the study. More than half (55%) of PrEP-indicated participants had low or no self-perceived HIV risk. CONCLUSIONS These findings suggest that further guidance is needed for health care providers in prescribing PrEP to transgender women. Greater uptake and adherence are also needed for optimal effectiveness.
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Affiliation(s)
- Jowanna Malone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sari L. Reisner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
- Division of Endocrinology, Diabetes & Hypertension, Brigham and Women’s Hospital, Boston, MA
| | - Erin Cooney
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC
| | | | | | - Asa Radix
- New York University School of Medicine, New York, NY
| | - Kenneth H. Mayer
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- The Fenway Institute, Boston, MA, US
| | - J. Sonya Haw
- Division of Endocrinology, Metabolism, and Lipids, Emory University school of Medicine, Atlanta, GA
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrew J. Wawrzyniak
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine
| | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrea L. Wirtz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Grov C, Westmoreland DA, D’Angelo AB, Pantalone DW. How Has HIV Pre-Exposure Prophylaxis (PrEP) Changed Sex? A Review of Research in a New Era of Bio-behavioral HIV Prevention. JOURNAL OF SEX RESEARCH 2021; 58:891-913. [PMID: 34180743 PMCID: PMC9729849 DOI: 10.1080/00224499.2021.1936440] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
In 2012, the U.S. FDA approved the first drug for use as HIV Pre-Exposure Prophylaxis (PrEP), which is nearly 99% effective when taken as prescribed. Although the manifest function of PrEP is to prevent HIV infection in the event of exposure, the drug has also had a significant impact on various facets of sexuality. In this review, we focus on research that emerged in the near decade since PrEP's approval, with a specific focus on the ways in which different elements of sex and sexuality have been impacted by gay, bisexual, and other men who have sex with men (GBMSM), cisgender women, and transgender individuals. We highlight evidence showing how PrEP has enhanced sexual self-esteem, improved sexual pleasure, reduced sexual anxiety, and has increased sexual agency for those taking it. For many, PrEP also serves as a gateway to improve routine health and increase sexual health-care utilization. Additionally, we review the question of whether PrEP is associated with increased sexual risk taking (i.e. risk compensation), and note that, although some data are mixed, PrEP is not intended as an intervention to reduce condomless anal sex or STIs: it aims to prevent HIV. Finally, our review highlights that, although the volume of research on PrEP among GBMSM is robust, it is underdeveloped for cisgender women and transgender populations and insufficient for inclusion in such a review for cisgender heterosexual men was. PrEP research with these populations is an important direction for future research. Finally, from 2012 to 2019, a single PrEP formulation and delivery method was FDA approved (oral emtricitabine/tenofovir disoproxil fumarate). As additional drug formulations (ie.g., emtricitabine/tenofovir alafenamide) and delivery methods (e.g., microbiocides, vaginal ring, injectable) come to market, it will be important to examine how these, too, impact the spectrum of sexuality.
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Affiliation(s)
- Christian Grov
- Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, New York, NY
- CUNY Institute for Implementation Science in Population Health, New York, NY
| | | | - Alexa B. D’Angelo
- Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, New York, NY
- CUNY Institute for Implementation Science in Population Health, New York, NY
| | - David W. Pantalone
- Department of Psychology, University of Massachusetts Boston
- The Fenway Institute, Fenway Health, Boston, MA
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50
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Chandler CJ, Creasy SL, Adams BJ, Eaton LA, Bukowski LA, Egan JE, Friedman MR, Stall RD, Whitfield DL. Characterizing Biomedical HIV Prevention Awareness and Use Among Black Transgender Women in the United States. AIDS Behav 2021; 25:2929-2940. [PMID: 33606134 DOI: 10.1007/s10461-021-03189-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Abstract
Black transgender women (BTW) in the United States experience disproportionate rates of HIV despite biomedical prevention interventions such as pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP). Using a sample of 490 BTW collected from 2014 to 2017, bivariate, multivariable, and multinomial analyses were conducted to determine factors associated with awareness and use of PrEP and nPEP. BTW living with HIV were more aware of PrEP than HIV-negative BTW. Structural, demographic, and trans-specific factors (e.g., experiences of homelessness, violence, and current hormone use) related to HIV risk were associated with PrEP and nPEP awareness. PrEP use was associated with behavioral HIV risks (e.g., STI diagnosis, having an HIV-positive partner, and needle-sharing) and may demonstrate risk recognition among BTW. Knowing someone using PrEP was significantly positively associated with PrEP use. Development of guidelines for PrEP and nPEP use for BTW should leverage the strengths of guidelines for other populations, while also acknowledging the unique risks for this population.
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